Last week I posted some musings on among other topics academic freedom and I got quite a response to this topic. The question arises how much am I allowed to talk about and what can my university do to control what I write (last week my university announced that they don’t want me to put their name on this blog because of a complaint they got about a satirical letter I wrote on my blog saying that mental health blogger Phillip Dawdy should be allowed to smoke in his appartment because of his mental health condition). They claim that this blog is for “personal” use it was a violation of their policy to have me use their name or letterhead for personal use. Which raises some interesting questions

First off, is this blog really “personal”? I mean all of the topics relate to my field in some way, which is medicine, health, medications, and psychiatry. Even the “personal” posts about things like my childhood or my emotions relate to my field because, well, I am a psychiatrist for Christ’s sake. What they were worried about was getting sued by somebody because I wrote a sarcastic letter supporting Philip Dawdy’s right to smoke in his own home. Which seems weird that they wouldn’t want their name associated with me.

Which gets me to the next point. If I were to say something like, for example, they treat professors more like corporate employees than academics, would they have the right to take action against me for criticizing my employer? Or is that a violation of academic freedom?

Legally there isn’t a good basis for academic freedom. How safe you are depends on where you live and whether or not you have tenure. In the US there is specific legal concept of academic freedom as apart from the 1st amendment to the US constitution that gives you the right to free speech without being retaliated against. But that protects you from retaliation from the government. So for professors at private universities, they don’t necessarily have legal protection, unlike in Germany, where academic freedom is the law. If you don’t have tenure, they can let you go for any reason. If you do, they have to let you go for cause, meaning you have to do something really bad, I guess. Maybe some of the legal eagles out there could write in and say what that is.

Remember that professor from Colorado who wrote a paper calling the 9/11 victims “little Eichmans”? Turns out they dismissed him for plagiarism and research misconduct, not for what he said.

In general your protection as a professor is all about what is in your contract at your university, and ultimately the culture of your university. So if having divergent views and saying stuff that is out there (we never do that here… Naaa…) is accepted as part of the culture of the university, then you are on good ground. Oh, and also if for-cause tenure is part of your contract.

After word of this blog and the issue of removing the name from my university got around, it piqued the interest of the American Association of University Professors (AAUP), and ultimately Inside Higher Education. I would quote the title of the article, but it contains the name of my university, which I am not allowed to name here.

You see how awkward this gets.

And how absurd.

Sarah Goodwin, head of media relations at my university, was quoted as saying “if you read [his blog] over a long period of time, you can see comments he makes that may be of concern.” She also said the ban on use of the university name on blogs was “across the board”.

I mean, give me a break.

As the article points out, Mark Bauerlein, an English professor who blogs for the National Review online, and Drew Westen, who blogs for the Huffington Post (I used to write for them too but would be ashamed to be associated with that swill these days) both prominently display the name of our university on their blogs.

Both Bauerlein and Westen are politically correct and garner positive media information for my university. Both also get mentioned in press releases, from which I have been unceremoniously dropped since writing my book, which was labelled as “anti-pharma” but which as anyone who has actually read it knows is just an honest review of the published literature on the benefits and risk of medications.

If you consider Goodwin’s comments, it tells you that: 1) someone from my university has been reading my blog for a long time, and; 2) they have been considering whether or not the comments should be censured.

Which is more evidence that they are thinking more like a corporation than a university, where the free exchange of ideas, regardless of the perceived value or political correctness of those ideas, is held to the highest standard.

Things are really starting to get weird around here.

I don’t know, maybe I am just an idealist.

Or maybe I should move to Germany.

A recent study from the National Cancer Institute has found that most cancer drugs are not worth the money. For instance, Erbitux, the drug used for the treatment of lung cancer, extends life by only an average of 1.2 months, hardly worth the expense of $80,000 for treatment. The authors calculated that extending life by one year for the 55,000 Americans who die of cancer would cost $440 billion. Other examples of basically useless treatments that will cost you the farm include Avastin and Nexavar, both costing more than $34,000 for a course of treatment.

Of course the usual suspects were trotted out in the form of doctors who stated that for some patients Erbitux is a miracle.

More egregious practices mentioned included doctors using drugs off label or aggressively treating people with Mercedes like drugs who had advanced stages of cancer. Of course Americans don’t like to talk about rationing of healthcare, which Rick Lippin MD has been talking about in the email circuit as well as the fact that more care can be worse care, and that profiting off of the dying should be prosecuted as a crime.

Hear, hear! (or is it Here, here?)

Maybe we as doctors should teach people to grieve their dead and dying, rather than enable them to flee from reality by throwing our expensive technology at their loved ones and colluding in the myth that everyone can live forever (e.g. “Aunt Mabel is fighting her cancer and gonna win” kind of nonsense).

Hat tap to John Mack (@pharmaguy).

I have been writing about the DSM process which isn’t always easy to do because the head of DSM-5, David Kupfer, MD, runs a pretty tight ship with his committee members, making them sign confidentiality agreements and not take any notes. Well since he said that there would be a “paradigm shift” and the sky is the limit for coming up with new diagnoses, there has been a lot of interest in the process.

David Kupfer, MD, Head of DSM-5

I recently wrote about the editorial by Allen Frances MD, head of DSM-4, criticizing the current process of DSM-5, and now there is a nasty response from the DSM-5 group, authored by Alan Schatzberg MD, James Scully MD, David Kupfer MD, and David Regier MD, that psychiatry blogger Daniel Carlat MD offered to edit for them to make it more respectful. Lol. A blogger offering to help the leaders of academic psychiatry tone down their language. Lol again.

I mean the damn editorial hasn’t even been published yet.

In their response to Frances Kupfer et al make dubious claims that “attorneys” had advised them to have committee members sign confidentiality agreements to protect “intellectual property”. They also charge Frances (as well as Robert Spitzer MD, who founded DSM and has been making the email rounds with criticism of the current process) with greed in wanting to retain royalties from a book he wrote about DSM-4 which would become outdated after the release of DSM-5. I mean anyone in the business knows that book royalties pale in comparison to the hundreds of thousands of dollars to be had doing pharmaceutical industry consulting and speaking. In fact one could even argue that doing things like editing books (which have essentially no revenue, because hardly anyone buys them) is a feather in the cap that helps you get those more lucrative gigs.

One of the diagnoses on the table is Female Sexual Dysfunction (FSD), a “disease” that if accepted would surely drive the drug companies to “identify and treat” these poor lassies with drugs like the testosterone patch (see “Wow A Drug To Have Sex Once More a Month? Sign Me Up!“) or Viagra or whatever psychotropic they could drug out of the medicine cabinet.

Turns out the medicalizing women’s sexuality may not be such a good idea. There is a long and jaded history of evil meddling by medical doctors in this area. The publication of the book Feminine Forever, whose thesis was that post-menopausal women become shriveled asexual crones due to an estrogen deficiency led doctors to put an entire generation of post-menopausal women on hormone replacement therapy (HRT), which in turn was later found to have caused tens of thousands of deaths from heart attack and other problems.

Then there were Masters & Johnson, the famous sex research team who concluded that women had more frequent orgasms than men.

Masters & Johnson on Meet the Press

This “research” however was based on looking through peep holes at brothels, and later their “research sessions” they conducted with each other. Virginia Johnson was Dr. William Masters secretary, and they “partnered” to have sex on a nightly basis for “research” purposes for years. Their report on 67 patients with unwanted homosexuality showing a 70% conversion to heterosexuality using “conversion therapy” was later disclosed as a fraud when noone could find any evidence of the patients. This bizarre “research team” should hardly be taken seriously about women’s orgasms.

Turns out that the DSM-4 has ‘Female Hypoactive Sexual Desire Disorder’ and ‘Female Hypo Orgasmic Disorder’ (I mean did the guy try going down on her?) as well as Dyspaerunia (painful sex). As a recent editorial pointed out, maybe the 43% of women with some type of so-called sexual dysfunction are acting “appropriately”.

I mean, maybe they’re with jerks and don’t feel like doing it?

The American Journal of Psychiatry has been soliciting editorials on the DSM-5 process. Too bad they rejected the editorial by Robert Spitzer MD who founded the DSM, and for FSD they have only this lame piece by a trio of MDs whose pharma disclosures read like a phone book. Lol. Sort of.

Ray Moynihan had a good piece in bmj on FSD (“FSD: The Making of a Disease”) in which he outlines how industry has moved in a serious way to pour cash in the “research and education” of this newly minted disorder, the rife conflicts of interest in the field, and the attempt by drug companies to medicalize female sexuality.

The past week has been an interesting one in the psychiatry field. After I described my experiences getting “un-invited” for my post on the DSM-5 Anxiety Disorders Committee, there was this followup in the Carlat Psychiatry blog. He described his own experiences getting blocked from a practice guidelines committee of the American Psychiatric Association (when I couldn’t think of anyone more scholarly and unbiased to do it).

The cause? A comment posted anonymously on his blog stating that Alan Schatzberg, MD, had pressured the DSM committee to loosen the guidelines for psychotic depression so that there would be an expanded market for the medication for depression he developed, mifepristone. Dr. Schatzberg was in the news last year because he had an NIH grant to study the drug but also was revealed to be the owner of four million dollars worth of stock in Corcept, a company that he co-founded and that makes the drug. Dr Schatzberg has since stepped down as Chair of the Department of Psychiatry at Stanford, source of the complaint against me that, yes, I had brought up two of the member of the DSM Anxiety Committee in the context that they were from Brown and Dartmouth, departments that were also sites of financial disclosure issues, so add to that my own university (which cannot be named), we pretty much have brought the circle to completion for the universities involved in last year’s financial disclosure broo ha ha. Also last week the CL Psych blog noted that Dr. Schatzberg in his speech accepting the Presidency of the APA stated that:

…some of the detractors in the press have voiced concern that some folks have earned too good a living, often by doing presentations…I have heard from colleagues and directly from one reporter asking me about one of my colleagues having too high an annual income…our members and residents have never taken vows of poverty…We need to ask ourselves how we have contributed to our own devaluation with which others seem to resonate, and we need to reverse the course. The rewards for our dedication should not be limited to a sense of pride, but we are also entitled to be paid commensurate to the challenge…

It doesn’t seem to me that Dr. Schatzberg has gotten the point that the American public is fed up with academic physicians been paid large sums of money from private industry and using their academic positions to promote their own and their industry partners financial advantages, especially if it impacts on patients. But there hasn’t been a lot of soul searching in psychiatry these days. I guess they’d rather spend their time getting people like me to shut up.

An interesting Anonymous followup comment to Dr. Carlat’s posting I was talking about earlier said that he shouldn’t wonder that people didn’t want him on their committees as he might use things he learns about in secret as “fodder” for his blog which he described as highly read. He also said you “can’t have your cake and eat it to.” Wa-aa? You mean if you want to be honest and transparent that you can’t serve on one of the APA committees? I guess because by implication they are corrupt and operate like the mafia? Hmmm, gonna go have some cake and think about that one…

Lolcat CAN have his cake and eat it too!

I have been following the death of Michael Jackson, and not only it [possibly] illustrates the death of another celebrity from prescription medications, but it also shows the importance of childhood abuse and neglect, and how the jerks who perpetuate it get off scott free.

Michael’s father, Joe Jackson, used to watch them rehearse and beat them with a belt if they did something wrong. He would trip them and push them into walls. One time he picked up Michael by one leg and beat him on the buttocks and legs. He took the proceeds of the Jackson 5 for himself. Just looking at Michael’s behavior as an adult it is obvious that he was a victim of childhood abuse.

But then, just in case you were unsure about this jerk, when interviewed by CNN after his son’s death, he said “we’re fine” and then went on to glibly promote his own new record company, taking advantage of the opportunity to be on the camera to promote his own business!

If this man doesn’t crawl under a rock, someone should suggest it to him strongly.

Joe Jackson is beyond redemption

Here is Joe Jackon with the Rev. Jesse Jackon (no relation?) after Michael’s death outside his home. I always thought that Rev Jackson was a twit. What is he a Reverend of anyway? The religion of his own ego?

Jessie Jackson and Joe Jackson (the father) laughing outside the home of Michael Jackson after his death.

After yesterday’s post on the Diagnostic and Statistical Manual (DSM) process “Retaliations and Beware of the Consequences” blew through the roof for record page views and stimulated similar confessions from other psychiatric bloggers about bullying by members of the American Psychiatric Association (APA), as well other commentary here and here and here. I seem to have wandered from a fairly tongue in cheek exercise in the DSM Shadow Team, founded to track the goings on of a secretive committee and have a little fun in the process, into a field of landmines.

This new article by Allen Frances, MD, who chaired the DSM-4 committee, criticizes the secretive approach by the current DSM-5 chair David Kupfer MD, who has insisted on secrecy, no note taking, confidentially agreements, and now I would add bullying of psychiatrists like myself who offer outside commentary. Dr. Kupfer has built up the Department of Psychiatry at the University of Pittsburgh into a research machine through developing the infrastructure of administrative personnel who help with the process of writing and submitting research grant applications for funding by the National Institute of Health (NIH). He is said to call out a “priority score” whenever he hears someone present research. Grants coming from Pittsburgh have the reputation of being technically excellent but not always exciting. It seems like he has brought this mass war enterprise approach to the DSM.

David Kupfer, MD, Chair of the DSM-5 Committee

All of this has gotten me reflecting on academic freedom. I mean, have not one but three organizations telling me to shut up (not counting the people in my personal life): the VA, my university (that which cannot be named here) and academic psychiatry. To whit, I am supposed to get approval to talk to the press from my local VA PR guy, but what this amounts to is that when I get contacted about something that they care about (i.e., Iraq), they shelve it and never get back to me. I mean, if you don’t think that pointing a gun at someone, pulling the trigger, and killing them can’t wreck your marriage or make you suicidal, that’s not my problem, so I don’t really get excited about getting censored about that stuff.

The current behavior of academic psychiatry in the DSM process is more troubling. By stiffling debate and creating a corporate type approach they are going against the very principles of science and academic freedom. One can only conclude that they feel insecure about the validity of their deliberations.

I also get upset about what I feel is my university treating me like an employee of a corporation rather than a professor in a university. I mean they should be glad to have their name associated with this blog when contrasted with other situations in which their name was associated with more questionable practices and they never said anything about it. For shame. And there are other professor bloggers who are much more lippy than I am and they list their universities on their blogs.

There are numerous examples of where a failure of academic freedom for exchange of ideas has had disastrous consequences, e.g. 30 million die in China applying Lisenko’s bogus scientific theories to agriculture which results in mass famine. In fact there is an organization dedicated to academic freedom. This is from wikipedia.

AFAF (Academics For Academic Freedom) [3] is a campaign for lecturers, academic staff and researchers who want to make a public statement in favour of free enquiry and free expression. Their statement of Academic Freedom has two main principles:

1. that academics, both inside and outside the classroom, have unrestricted liberty to question and test received wisdom and to put forward controversial and unpopular opinions, whether or not these are deemed offensive, and
2. that academic institutions have no right to curb the exercise of this freedom by members of their staff, or to use it as grounds for disciplinary action or dismissal.’

AFAF and those who are part of the campaign believe that it is important for academics to be able to express their opinions - not just full stop, but to put them to scrutiny and to open further debate. They are against the idea of telling the public Platonic ‘noble lies’ and believe that people should not be protected from radical views.

Well said.

I just found a way to save 25 billion dollars a year for President Barack Obama’s healthcare plans. That is to cut out angioplasty (currently called percutaneous coronary intervention, or PCI), for which multiple studies, including one in the June 11 edition of the New England Journal of Medicine, show are not useful for patients with stable coronary artery disease (CAD). The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack and death in people with stable heart disease doesn’t stop doctors from performing them.

In this procedure doctors put in a guideline in the coronary arteries and blow up a balloon that flattens plaque against the wall of the artery and opens up the artery or they insert a stent to keep the artery open. Sound good and makes sense, too bad it doesn’t work.

“There are people in the cardiology community who don’t believe the results. They don’t believe it applies to the patients they see,” Dr. Judith S. Hochman, director of the Cardiovascular Clinical Research Center at New York University School of Medicine, was quoted as saying. “So we still see a lot of angioplasty being done without patients really understanding that it will not reduce their chances of heart attack or death.”

But I’ll give the reason why they still perform 1.2 million of these procedures every year. It is pretty simple really. Greed.

Nancy Nielsen MD, President of the AMA, opposes healthcare reform

Doctors always say things like they don’t believe the data, or that isn’t the way it is in my practice. Since they won’t believe in science, data or reality, maybe we should just play their game and use some wizadry to get them to do the right thing and stop doing these useless procedures.

When I count to 3 you will stop performing angioplasties

Or maybe one of the Obama guys should have some guts and stand up and say we’re not gonna pay for those things anymore.

[Update: see comments section for reference to acute coronary events where PCI has demonstrated efficacy and citation by Marilyn Mann which was made immediately after I posted this on June 25 which I assumed was sufficient for anyone reading this; that didn't stop a cardiologist in another blog from going on the attack and saying that since the COURAGE trial showed lack of efficacy in reducing heart attacks in stable coronary disease these procedures have declined. Even so they are still estimated to be about 1/3 which is too many and some cardiologist lately have gone to jail for performing PCI on people with little or no heart disease. So my initial statement that 25 billion dollars could be saved is not correct. It is more like, um, 8 billion.]

An article in press in Psychiatric Times which I have posted here has been circulating around that represents a remarkable critique of the process of revising the Diagnostic and Statistical Manual (DSM-5) by the American Psychiatric Association, Chaired by David Kupfer MD. What’s more chilling is that it is authored by Allen Frances, MD, who chaired the committee to write DSM-4. Dr. Frances comes up with some pretty strong language, e.g.:

The work on DSM-5 has, so far, displayed an unhappy combination of soaring ambition and remarkably weak methodology.

He then goes on to explode the statements by Kupfer that the DSM-5 will lead to a “paradigm shift” in psychiatry, which he describes as an “absurd statement” based on the fact that there still is not a single lab test for diagnosis, and the gains are small and incremental in descriptive research. In the absence of evidence, changes in diagnostic criteria are arbitrary and often driven by a single strong member of the sub-committees. Furthermore, the incorporation of sub-threshold diagnoses as official psychiatric diagnoses will be a “bonanza” for drug companies who will expand their markets to new legions of the “newly” mentally ill and rush to “educate” doctors about the new criteria, which they will use to expand drug usage. It will also serve to expand stigma. The cost to research of having to re-do studies because the diagnosis has changed, or unintended consequences of diagnostic changes, are good arguments for his point that one should do as little as possible to change things. 

Dr. Kupfer, however, was quoted as saying “There are no constraints on the degree of change.” Instead of being conservative and guarding against new and goofy diagnoses, they are letting the barn doors fly open. To whit, prodromal syndromes like “pre-psychotic” or at risk for mood disorder are being considered as diagnoses, which will create a whole group of “non-patient patients” who will be forever labeled even if they never develop the disorder. Also behavioral impulses like excess of food, sex, internet, or whatever are up for grabs as diagnoses. That will take something that is a moral problem and turn it into a medical disorder. Dr. Frances writes:

Getting as much outside opinion as possible is crucial to smoking out and avoiding unforeseen problems. We believed that the more eyes and minds that were engaged at all stages of DSM-IV, the fewer the errors we would make. In contrast, DSM-V has had an inexplicably closed and secretive process. Communication to and from the field has been highly restricted. Indeed, even the slight recent increase in openness about DSM-V was forced on to an unwilling leadership only after a series of embarrassing articles appeared in the public press. It is completely ludicrous that the DSM-V Workgroup members had to sign confidentiality agreements that prevent the kind of free discussion that brings to light otherwise hidden problems. DSM-V has also chosen to have relatively few and highly selected advisors. It appears that it will have no Options Book to allow wide scrutiny and contributions from the field.

The secretiveness of the DSM-V process is extremely puzzling. In my entire experience working on DSM-III, DSM-III-R, and DSM-IV, nothing ever came up that even remotely had to be hidden from anyone. There is everything to gain and absolutely nothing to lose from having a totally open process…

I have decided to write this commentary now only because time is beginning to run out and I fear that DSM-V is continuing to veer badly off course and with no prospect of spontaneous internal correction. It is my responsibility to make my worries known before it is too late to act on them. What is needed now is a profound mid-term correction toward greater openness, conservatism, and methodological rigor. I would thus suggest that the trustees of the American Psychiatric Association establish an external review committee to study the progress of the current work on DSM-V and make recommendations for its future direction.

Pretty strong language.

Add to Dr. Kupfer’s strategy of: 1) keep everything a secret; 2) make members sign confidentiality agreements; 3) allow no note taking; 4) ignore outside experts and comments; we can now add, 5) intimidate and ostracize academic psychiatrists whom you can’t ignore.

Readers know I have been writing about the DSM Shadow Team to keep track of the goings ons of the “real” DSM. Well apparently a post I wrote about a proposed Developmental Trauma Disorder in children really ticked them off, as I got an email from someone on the DSM Anxiety, OCD, PTSD and Dissociative Disorders committee whom I thought was a ”friend” un-inviting me to be an author on a paper about another topic (that was after I had already spent several days working on the paper). My crime? Stating that two of the committee members were from Brown and Dartmouth, where psychiatrist colleagues of theirs had gotten caught up in financial misconduct allegations. And one of them tried to kill himself. Seems like a lot of academic psychiatrists are doing that these days.

I have people point out to me all the time the fact that I come from a psychiatry department which has financial disclosure problems, like this one at Gooznews, and they usually make no effort to avert any implications about it, but I stand up and take it like a man.

The other thing that gets me is that the paper I was “invited” to co-author was a response to (drumroll) another one written by some psychologists on the relationship between dissociation and trauma and that I was invited because (drumroll) I had written a post about the paper critiquing it in my own unique and photo-shoppy way. Fact is I got an email from one of the psychologist authors of the paper calling me puerile and stating that he was embarassed to be from the same university… but inviting me to write a response for the journal… which I am doing now… hemph. I mean psychologists can get pissed but still debate… as for psychiatrists… well.

What was particularly chilling about this episode is that the email was copied to all the members of the committee, implying that I was now persona non grata and should be shunned by what are in fact my peers in the anxiety disorders and trauma community of academic psychiatry. I was debating whether to talk about this here but to take this “hit” in silence just re-inforces the mafia type atmosphere of bullying and intimidation that rules the day in academic psychiatry. This lack of transparency and honesty and abuse of power has led to the dreadful situation which academic psychiatry is in today, where they are universally despised by try and play it off as the evil machinations of scientology and other conspiracy theories. I, for one, however, am not going to play along with that game anymore.

Who knows, they may have been behind the anonymous letters sent to the Dean of my university complaining about another post that led them to ask that my university’s name be removed from this blog with which I complied, or the threats to go to the state medical board.

[Update: See Dan Carlat MD blog for followup to this post].

I have had someone writing to complain about my blog stating that Philip Dawdy needed to smoke for his mental condition and that he shouldn’t be kicked out of his appartment for smoking. I mean he is smoking in the privacy of his own home. Why should those Seattle Eco fascists be able to kick him out of his own home?

Anyhoo I have had official letters of complaint to the Dean of my university and the acting chair of my department and they have asked me to remove the name of my university and letterhead from my blog with which I have complied. So if you want to know my university you can use google.

Readers of the Drug Safety and Health News blog know that my mother died when I was four and a half years old and that last year I discovered where her ashes were buried and had a ceremony with my siblings where we put a tombstone we had bought for her over the site. My father re-married shortly after my mother’s death and we were instructed to refer to our step-mother as “mother” and our biological mother by her name (i.e. “Laurnell”).

Growing up calling my mother by her name instead of ”mother” had a weird effect on my brain. It was like my biological mother wasn’t really my mother, just some sort of person that happened to drift through my life. Recently I have been trying to untangle these threads in my brain.

Step-mothers are one of those weird topics like bastards that noone wants to talk about.

I started wondering where the word “step-mother” came from anyway. Here is what I found:

step-

O.E. steop-, with connotations of “loss,” in combinations like steopcild “orphan,” related to astiepan, bestiepan “to bereave, to deprive of parents or children,” from P.Gmc. *steupa- “bereft” (cf. O.Fris. stiap-, O.N. stjup-, Swed. styv-, M.L.G. stef-, Du. stief-, O.H.G. stiof-, Ger. stief-), lit. “pushed out,” from PIE *steup-, from base *(s)teu- (see steep (adj.)). Etymologically, a stepfather or stepmother is one who becomes father or mother to an orphan, but the notion of orphanage faded in 20c. For sense evolution, cf. L. privignus “stepson,” related to privus “deprived.”

Hmmm.

Anyhoo I coincidentally saw someone writing on the internet about adopting their step children. I started to wonder if I had been adopted so I asked my brother who told me that he didn’t think so. “Wasn’t it enough just to get married to our Dad?”

I looked into it, and the laws about parents and step-kids are pretty specific. If you don’t adopt your step-kids there is no legal relationship with them. So that if your spouse dies, you have no control over their medical care, you have no rights to them, you can’t even get them into school.

Over the past year I have gone through a much overdue grieving process for my biological mother which resulted in my finally coming to grips (I guess) with the fact that… she is dead.