Saturday, March 10, 2007

No You Don't

I think Dinah raised an interesting topic in her last post. Can psychiatrists ever refuse to treat someone, or to treat them only under certain conditions?

I'll leave Dinah and Roy to talk about the free society way of handling that; I can address what happens inside the walls.

The patients I treat get locked up because of persistent misbehavior or persistent high-risk behavior. (I don't call it 'self-destructive' behavior---even though it is---because inside the walls that term has a very different connotation.) I don't really ever have the option of not treating someone. My clinic is never too full to accept new patients and our jail/emergency room never goes on 'fly-by' status due to lack of bed space. So, I get all comers.

That being said, I do have certain limits. By the time I get my patients they are generally ready to accept the idea that their behaviors are getting them into trouble. The biggest issue is how to handle the interventions from that point on.

The biggest trick with treating substance abusers is that there's a big difference between what they say they want and what they actually want. They say they want to be drug or alcohol-free, to give up 'fighting the system' and to get themselves together. But at the same time they want to be in control of treatment, in control of their environment and to have it all done on their own timeline.

This is a setup for frustration.

Fortunately, it's all manageable. The key is to be upfront about expectations and limits and to be true to your word. Inmates can accept a 'no' but it's a very very bad idea to imply you can or will help them with something you have no control over. I don't make housing or cellmate changes, I don't order lower bunks or special diets, I don't make phone calls or transmit messages for inmates. That's pretty much the easy part.

Occasionally inmates aren't happy about that. Very rare inmates may escalate their requests along a continuum that I can pretty much predict: a hint for a favor turns into a direct request which turns into a demand which turns into a threat. Once you reach the demand/threat point treatment stops.

So getting back to the idea of conditional treatment, my only real condition is the requirement for safety. Once a patient gets to making a threat of violence to me, to himself or anyone else, treatment stops and safety interventions begin. That's really the only way to get things back on track.


Rach said...

great post Clink! I'm interested to hear what Dinah and Roy think too.

A slightly different question - how do shrinks get started with treating patients? when you finished your residency, did you already have patients on your docket, or did you just hang a shingle and wait for the phone to ring?

Dinah said...

Seems you would have a more controlled environment with regard to what's available inside the walls.

I count on one hand the number of times I've refused to treat anyone who wants to come. I did recently tell a new referral who mentioned over the phone that she was on a huge dose of Xanax (I think it was 8 mg a day) that I could never be comfortable prescribing this and I wasn't the doc for her. No one has ever threatened me, knock on wood, and that-- or any terribly intrusive behavior such as stalking me, showing up at my home, or any violent act in or around my office-- would be treatment-enders.

Rach, most people take a job out of residency and start a part-time practice. I think hanging a shingle as the only career move would depend on how many other private practice shrinks are around, what kind of connections you have, how much debt you're in, how much you need an immediate and reliable source of income and health insurance (sort of like any other private practice).

Patient Anonymous said...

This is timely. I just had the second of two psych evals. The last was rather confusing as it was briefer than I had anticipated and there was a lot of ground to cover including: Meds, Family History/Trauma, Bipolar, Self Harm, Hospitalizations, ADD and Aspergers.

The only thing I could get out of the fellow was his five med recommendations. Granted, I dumped a dossier on his lap and I know I can't expect him to come up with something right on the spot but some more feedback would have been helpful.

He did tell me that ongoing consults with him as a psychiatrist would not be helpful to me as they would just exacerbate my problems with "my issues." He did not elaborate further. However, he did provide me with a resource for group therapy.

This seems confusing and somewhat counterintuitive to me.

I reminded him that Aspies don't do well in therapy (despite the fact that I already have a therapist--which sometimes works, sometimes is frustrating.)

He said the fact that I already have a therapist, a neurologist, and a GP should be sufficient.

Erm...I thought that psychiatrists were good to add to the mix for med management and further assistance for those of us that are disordered.

I look forward to seeing his report? And to see if he, in his professional opinion, deems me an Aspie.

Steve & Barb said...

Good topic to blog about. Sure, we can refuse to treat someone, but this should not be done lightly.

Folks I would probably refuse to treat (I'm talking outpatient, here):
-people who threaten me (I think I would've refused to treat Robert DeNiro's character in Analyze This, but I recall it was an offer that he couldn't refuse)
-children (I don't do kids)

Those are all the absolutes I can think of. I cannot recall anyone I have actually "refused", though there are many I have not offered to treat, usually because of not having the time, or maybe the skills needed (I don't do analysis, and am not good with CBT).

Payment has not been much of a reason in the past either. When I was in private practice, I did take several insurance plans, but had a fair number of self-pays. When uninsured folks would call asking for rates, I'd tell them what I usually charge. If they found that difficult to manage, I'd usually ask them what they could afford to pay me. I think I always accepted what they offered.

I guess that's where the "privileged" comment from Lily comes from. I do feel privileged (that my parents put me through college, that I was able to put myself through medical school, that I was smart enough to make it through medical school, that my skills and services are in demand), so I felt that I could cut people slack if they really want help.

If someone refuses my advice, I accept it and continue to find acceptable alternatives, unless I feel the he is putting himself at unacceptable risk. That is where I might draw a line. I think harm reduction is a good strategy, but sometimes you have to just say "No."

(which is right? ...say "No." or ...say "No".)

Steve & Barb said...

P.A., he might not want to take you on simply for scheduling reasons. There are only so many hours in a day, so sometimes docs may not accept someone because they are nearly full, but accepting a one-time consultation is manageable. So this should not be taken personally.

Rach said...

That's what my psychiatrist has done - has made it widely known that he's not taking on any new patients... I think he had to do it, or it wouldn't have surprised me if he ended up shutting down his practise completely.

Here, at least, most shrinks are overwhelmed with patients.

Anonymous said...

I'm sure as an experienced 'clink shrink', you would realise that there are threats and there are threats.

Fact is that the prison environment generally teaches people - who often start with limited social skills - that the best way to get what you want is to threaten people. Prisoners do it to each other, guards do it to prisoners, prisoners sometimes do it to guards and the system as a whole is more likely to respond to Attica riot type threats than to reasoned advocacy, appeals to humanity or assertions of legal rights.

I don't work in the prison system, but I've been 'threatened' by recently released prisoners.

More often than not it seems a sign that the ex-prisoner is at a loss as to how to otherwise express distress/disagreement or stake out a negotiating position. I generally try to suggest other ways of communicating and negotiating and while they're not always taken up, I'm yet to be attacked.

I suspect if I ever am seriously attacked, it won't be preceded by a clearly stated threat.

Of course you have to decide for yourself how to best keep yourself safe and define your therapeutic relationships. But I would suggest that making 'threats' a line in the sand is to set a pretty arbitrary boundary.

ClinkShrink said...

Michael, a threat is a threat and there's nothing arbitrary about an inmate who says, "If you don't give me X I'll do Y." That's a pretty clearcut statement. Fortunately, as I said in my post these inmates are very rare. And yes, of course I attempt to educate the inmate about more appropriate ways of getting what they want or need. They may listen, they may not. Fortunately (knocking on wood) I have never been assaulted in over ten years in corrections. (I was assaulted once as an intern in free society, in the ER.) But I have had colleagues who have been assaulted and I work in a system with one of the highest internal homicide rates in the country so I'm pretty serious about threat management.

Anonymous said...

Clinkshrink, I assume that when you give the example "If you don't give me 'X', I'll do 'Y'", that 'Y' is always an act of violence towards you.

Otherwise maybe they're just responding in kind to someone who says "If you don't give me respect, I'll discontinue treatment".

Like I said, prisons are run on threats, and threatening to discontinue treatment is also threatening the patient's chances of improved security classification or early parole (or at least it is in the NSW prison system).

The prison systems here in Australia aren't as violent or overcrowded as I'm told they are in 'the land of the free', but after a few years, a lot of prisoners end up pretty incoherent in just about every non-physical form of expression (especially if they're among the many who receive heavy doses of atypicals for prison management rather than therapeutic reasons).

Again, I reiterate that your safety has to be your call. But I also reiterate that if my experience is anything to go by, all you are doing is filtering out the patients with the most severe communication problems and perhaps not protecting yourself as well as you seem to think.

ClinkShrink said...

Participation in treatment isn't a requirement for reclassification or parole here. You seem to be implying that inmates make threats that are justified based on their environment and how they are treated. Not so. Some inmates---and again, the ones I'm talking about in this post are rare---make threats as a means of gaining control of treatment and to intimidate the clinician into giving them what they want (those 'heavy doses of atypicals' you mentioned, which they sell or trade).

I don't discontinue treatment to 'gain respect', which you also seem to be implying. I stop outpatient treatment and put the inmate on observation status when he persists in making threats of self-harm and can't be engaged in any less intrusive way. If it's a threat to others, segregation status is sometimes indicated. Again, this only happens if less restrictive therapeutic interventions fail.

Patient Anonymous said...

roy, Thanks for your personal acknowledgment. It did later come up that he did have some scheduling/patient load issues and was making a job change but he said "it was neither here nor there."

It still confused me that his comment about "my issues" would gt in the way of further/ongoing psychiatric help.

I'm not taking it personally, I guess I just don't understand as I am trying to navigate what would be best in pursuing the overall goal of managing my mental health.

Anonymous said...

Sounds like another world over there then.

I'd heard anecdotally that antipsychotics were used 'recreationally' in US prisons but had been unsure whether to credit it.

If it happens over here, it must be very rare, as neither the studies I've read nor the prisoners and ex-prisoners I work with have ever mentioned it - though other kinds of drug use in prison sure are.

The organisation I work with gets lots of complaints from prisoners forced to take them when they don't want to though (and they are not indicated). There has recently been a UNHRC finding against the NSW prison system on that count.

Still, I guess 'a day off your face is a day off your sentence'.

Psychiatric treatment per se isn't a formal requirement for improving classification or parole in NSW (unlike, say, anger management and sex offender courses for certain types of offenders) but if you have a diagnosis of mental illness that is 'untreated' you will have next to zero chance of either. In fact you would be at increased risk of being made a 'forensic patient' (i.e. mental health prisoner) with the associated risk of not even being released when your sentence is completed.

Of course prisoners are perfectly aware of how it works and a lot of complaints we get are from prisoners who are being denied therapy that they don't really want, but know that they will suffer consequences for not receiving. Its not usually the therapist who is withholding treatment, but an effect of administrative shortcomings (or bastardisation).

Are you saying that if a prisoner threatens to self harm if he doesn't get a particular therapy you will discontinue treatment?
Not sure how that's meant to protect you.

So if I was a stressed out prisoner who came to you saying "I can't handle it doc. If you don't give me something to calm me down I'm gonna neck myself" it would be off to the obs cell with me?

I must admit that a similar outcome would be likely in Australian prisons too, as guidelines and regulations tie the therapist's hands on the matter. But there has been an outcry from clinkshrinks over here about it (e.g. see "Ethical Issues in the Prevention of Suicide in Prison" by Douglas Bell; Australia & New Zealand Journal of Psychiatry, Vol 33 pp723-728 [1999]).

And I wasn't implying that you discontinue treatment to 'gain respect' (that would require a pretty odd definition of 'respect'), but I can see that in my attempt to make my earlier sentence match the grammatical form of 'if you don't give me X, I'll do Y' I lost something in translation.

I probably should have written "If you don't respect my rigid boundaries, I'll discontinue treatment".

And I'll again emphasise that I respect your right to set those boundaries. NSW has the highest rate of prison homicide in the country but its still less than five confirmed homicides per 10,000 prisoner years (although some of the 'suicides' are a bit suspect) and only a tiny proportion of those involve non-prisoner victims. So I suppose we can afford to be a bit more complacent.

Still, I've gotta wonder how your approach is making the prison safer for staff or prisoners.

Dinah said...

I'm sticking my neck in here where it doesn't belong, but hey:

Clink sees a trillion patients a year, I imagine she has only refused to treat a handful at most over the years. She means (and she'll correct me if I'm wrong) that she refuses to treat someone when they say, "If you don't give me Valium, I'll break your f***ing neck."

ClinkShrink said...

I think the confusion is coming in over the definition of 'treatment' and exactly what it is I'm discontinuing. (Poor Dinah dislikes discussions about defining disease so defining 'treatment' may just drive her over the edge---sorry kiddo, you might want to skip this comment.) What I'm saying is that if an inmate comes to my office threatening harm and doesn't respond to crisis intervention and supportive counselling, and continues to threaten self-harm, then I will discontinue these interventions (since they are obviously not being effective anyway) and switch into 'harm prevention' mode. The difference is in intervening to prevent a situation from getting worse as opposed to providing intervention to make a situation better. I don't view the use of a suicide observation cell as a therapeutic intervention but something that is done out of necessity. A last-ditch measure. It's not for my protection, it's for the inmate's safety.

Similarly for inmates who threaten the safety of others (a cellmate, an officer, a parole hearing officer) I will discontinue therapeutic (ie counselling) if it not effective and switch into 'harm prevention' mode through the use of a segregation cell. Harm prevention is what's done when ineffective therapeutic modalities fail. And yes, I think this does enhance the safety of the institution.

Placing someone on observation status or in a segregation cell is not cutting someone off from all contact with mental health services. These inmates are rounded upon regularly by a team of people including a representative of the psychology department.

Hope this clarifies things.

Five homicides per 10,000 prisoner-years? Oh my. We've had six this year.

Your experience with atypicals is interesting; here quetiapine has actually been banned from the entire prison system due to abuse (crushing and snorting). To be fair, any sedating medication has trade value here (one pill of amitriptyline selling for 50 cents to a dollar a pill).

I started commenting on the interesting case you linked to but it got too long so I'm turning it into a blog post instead. Thanks!

Steve & Barb said...

Yes, Dinah, that's how I read it, too.

Didn't we podcast about Seroquel being abused in prison by combining it with cocaine, as a Q-ball?

Anonymous said...

why are patients asking for early reflls of abilify?? could it be being used like the seroquel?