Wednesday, August 15, 2007

Continuing with that thought....

I started to write a reply to Jayme, who commented on my post Shrinks Aren't Perfect, then I realized the answer was its own post.

Jayme wrote:

I am having a hard time empathizing with psychiatrists being falsely portrayed in the media when psych patients are portrayed far worse, more often, and with incredibly damaging consequences. I don't see much discrimination against psychiatrists because of bad media portrayals. I'd really like to see you gripe about society's lack of empathy toward psych patients instead of your own. I hope this is taken with the spirit it was intended. Thank you.

Absolutely, I agree that the media portrayal of people with psychiatric disorders is awful and stigmatizing. I don't really care how the media portrays psychiatrists for my own sake--I make a living, I have a blog, what more could I want? I knew the profession carried stigma when I chose it, and I chose it. People don't choose to get mental illnesses. The media tends to portray the mentally ill in ways that obliterate any other aspect of their being. Often psychiatric patients are depicted as weird, creepy, or outright dangerous.

The psychiatric setting is used in media for 1) the entertainment value complete with distortions and 2) in terms of story development, the setting can often provide insights/information into a character that couldn't be gleaned in other ways--though this is more true in terms of written/literary plots where point of view limits access to information.

The issue of portraying the psychiatrist negatively is not one that means much to me-- face it, some psychiatrists are pretty weird. I may be pretty weird. The issue of portraying psychiatry in a negative light is that it creates a negative aura around mental health care delivery which spreads out to include the patient, it fosters the stigma, and it makes people with problems hesitant to seek care. You're going to go see a psychiatrist? Shrinks are so messed up themselves, how can they help you? You're doc might turn out to be Hannibal Lechter (pass the Chianti, please) or that transvestite serial killer from Dressed to Kill. Or maybe he'll just be twitchy and pompous like Niles Crane on Frasier.

In the movies, psychiatric patients aren't normal people living normal lives who either get overwhelmed with their problems or get afflicted with a mental illness, who then see a doc and get helpful treatment from a kind and caring person. There's nothing about what one sees on TV or in the movies that would make you want to see shrink.

An "Anonymous" commenter has been kind enough to provide the reference to the Letter I read in Psychiatric Times: The author is Harvey Roy Greenberg (not of Shrink Rap) and Anon writes:

Re: Dr Melfi. The guy who has the same middle name as your co-blogger did not write that she sometimes made mistakes or failed to be empathic all the time. He wrote that her treatment was riddled with EGREGIOUS mistakes and that at times she betrayed a STARTLING lack of empathy. Never watched the show, can't say what she did or didn't do,but there are mistakes and then there are mistakes. No shrink can be empathic all the time but when it comes to a STARTLING lack, then that shrink should refer or the patient should run. Shrinks everywhere: please try to remember that this is a TV character. It is wacko to get this connected with a TV character. As for Beautiful Mind, the ECT and other treatment depicted therein date back many years. If someone suggests that their patients watch it they might also add that disclaimer. This other Roy guy was not writing about you, but you sure took it personally and your reaction seems way out of whack with the provocation. I'm just not getting it.

The Sopranos is different from other media portrayals of psychiatry. Yes, I know it's a TV show, and yes, I've seen every episode (thanks to Blockbuster and HBO on DVDs). Tony Soprano is a nice normal Mafia boss, he "works," he loves, he functions as a Mafia boss will function, and he seeks psychiatric care because he starts having panic attacks. He may be evil, but he's not crazy, and his mental illness is a small part of who he is and what he does. He is a difficult patient-- he steals his doctor's car to have it repaired, he declares his love for her, he sends her flowers, he curses her out and leaves, he has affair with a woman he meets in her waiting room and that patient commits suicide after Tony ends the affair. The list goes on. We also get to see Dr. Melfi's therapy/supervision sessions so we have some insight into just how conflicted she is about treating Tony. Off hand, without reviewing every episode, I don't recall any Egregious errors. I guess the question might be asked, What would be an egregious error in psychotherapy? Dr. Greenberg is a psychoanalyst, perhaps his idea of an error is different than mine? A Startling lack of empathy? There are moments when it would be startlingly difficult to empathize with Tony--especially as a woman listening to his continued sexual indiscretions. Sympathy? Well maybe, but Empathy? He spares Dr. Melfi the details of his violent life--in the first season he talks about working out difficulties with an adversary where he cages running the guy down and breaking his legs as "We had coffee."
Finally-- Roy is back soon, and our regular podcast schedule will resume shortly.


Anonymous said...

Hannibal Lecter, not Lechter, but yes, some shrinks are lecherous.

As for Melfi, if you ,as one who has watched the show, believe that Tony is evil and not crazy, whatever that means( ummm, what does that mean?) then why would she treat him at all if this is, in your view, a realistic portrayal of psychiatry?
Stealing cars, striking up waiting room affairs that lead to suicide? Why would she put herself and her other patients at risk? Oh yeah, those other people... I think that would have to count as an Egregious error because she does not operate with the safety measures one assumes would be in place if the guy was in prison. She operates on TV and that is really the only good reason to treat the guy in private practice or even at all.
To my knowledge, evil is not really something that is amenable to psychiatric treatment. Panic attacks? Okay, but Tony doesn't need a prescription since he is a mobster and can get any drug he wants.Besides, if your spend your life killing and you know that you could be next, you should have to suffer a panic attack now and then.It's only fair.

it's a tv show it's a tv show it's a tv it's a tv show it's a tv show it's a tv show and I can't imagine why real psychiatrists would become so enamored of a tv shrink who sets out to treat "evil".

Anonymous said...

I don't think that anyone is "enamored" by Dr. Melfi. It is just interesting subject matter to discuss. It's fun--and we all know it's TV. TV is also a reflection of our lives. Tony did need a presciption because he would never go to the black market for an antidepressant. Cocaine? well, of course. And remember--Dr. Melfi didn't know in the beginning the Tony that we, the viewer, knew. Afterall--this is TV.

Steve & Barb said...

Anonymous makes some of the same stigma-enhancing errors that a previous commenter described as inaccurate media portrayals of people with mental illness or with psychiatric symptoms.

"If you... believe that Tony is evil and not crazy... then why would she treat him at all...?"
Everyone who seeks treatment is not "crazy" and most of our patients do not display behaviors that anyone would label "crazy". (As for the *evil* part, while evilness, per se, is probably not amenable to therapy or meds, the consequences of evil could be, I suppose. Now, there's a good story... Hitler in psychotherapy.)

"If you spend your life killing and you know you could be next, you should have to suffer a panic attack now and then. It's only fair."
This comment is quite irksome. Granted, Tony is a "bad" person and deserves some sort of comeuppance. But the comment betrays the unfortunate feelings that many have towards people with mental illness or addictions -- (1) that they somehow "deserve" the symptoms that they have due to past transgressions, mistakes, or other choices; and (2) that they are less deserving of empathy and compassion because they have "brought it on themselves".

I'm not talking about Tony Soprano here, but this general feeling that, unfortunately, most people have to some degree towards psychiatric illness. Folks used to have the same stigma towards people with epilepsy and people with cancer -- that it was some kind of karmic consequence.

It is with this same stigma that many workers in prisons and emergency departments (among other places) feel that people who are addicted to heroin or meth or alcohol should get minimal to no treatment of their withdrawal symptoms, because they need to be taught a lesson or deserve what they get or are not deserving of compassion.

Do we similarly withhold treatment for DKA when people with diabetes are nonadherent to their diet? Withhold chemotherapy for smokers with cancer? Withhold coumadin to prevent blood clots in folks with morbid obesity?

Are we as a society moving towards or away from this concept of conditional compassion?

Anonymous said...


I was DIRECTLY quoting Dinah when I said "evil, not crazy". ("..if you, one who has watched the show,....." )And, I did say "umm what does that mean?" by which I meant, gee isn't "nice"???! to see a shrink put it that way. I don't think anyone who seeks treatment is crazy. I have been called crazy. Didn't like it. Didn't exactly love it much when told that i was not crazy but had a mental illness. It was better than crazy though. I didn't directly call Dinah out on her use of the word crazy because she gets a little what's the word... defensive? So since you called me out, I now pass it back and you can send your message about making "stigma enhancing errors" on to Dinah.They belong on her head, not mine.

About my comment that TONY might deserve his panic attacks, bear in mind I was talking about TONY, a man, make that tv character, that Dinah diagnosed as evil. My comment cannot "betray" any feelings on my part that people with mental illness or addictions brought it on themselves unless I really really hate myself (which I do enough of the time but who cares?)because I have done my time in rehab holes where you don't get to take a pee in private and I come from a very long line of people with mental illness and addictions. And throw epilepsy in there while you are at it. Don't preach to me about stigma. I said that it wouldn't break my heart for a mobster killer or a serial rapist, who walks the street freely, to have a panic attack or two, or three. "It's only fair" because of all the people killers and rapists leave in their wake. Is it really fair for a Tony guy to have his freedom and not have to suffer anything? If you believe that prison is all about rehab, it isn't. There is some of that, but society sets prisons up for other reasons such as punishment, the protection of other people in society and as a caution to others to mind what they do. People end up there for all sorts of reasons, right and wrong. Gee, I wonder which that Soprano guy would prefer, prison or a panic attack.
As for Hitler, had he not offed himself, the judges at Nuremberg would have let him have his panic attacks. I don't think there are any jokes to be mined from that sort of thing, ever.
Don't tell me about stigma. I know all about it. I don't even like the sympathetic cluck cluck looks you get from people after you get out of hospital. I hate it all, the meds, the constant blood work, the staying quiet when people who don't know make dumb remarks about us "crazy" people, the no thanks, i will have ginger ale because I am allergic to alcohol, the lets try this pill because the one you were on all that time has super duper bad side effects and this brand new one only has the side effects nobody really knows about yet but the main thing is that you stay stable, the comments like if i were you i wouldn't have kids because its genetic, the sorry but we can't sell you life insurance, the endless lying to people about why you can't do all the things they do or the things you said you would, the what is on that medic-alert bracelet questions, the not knowing when it, any of it, will strike and therefore being afraid to commit to anything or anyone, the way it feels after you realize that during that last episode you hurt a lot of people or you made yourself look like an idiot and maybe worst of all, the panic attacks in front of all those people.the knowing that you are are at the mercy of some doctor who gets to decide when or if you can go home, the bad shrinks and it has been enough years to rack up some doozies. and even the good ones, just because you know you need them and that is tough to swallow.yeah, i know you know all about IT. and you know what? despite my laundry list of things i hate about IT I am lucky ,lucky, lucky because my shrink would never ever ever have me wait in a waiting room with evil.other reasons too.
as far as conditional compassion goes, lets make sure to get some liberals to lobby for all killers and rapists to have cells that look like "the retreat" at Shep-Pratt.Just so they don't have suffer.Get some stroger glasses while you at it.

Anonymous said...

Why did Tony need a prescription? Did it make him reform orfeel remore for his evil ways? Or does it just soothe his mind enough to enable him to go and commit another heinous act? He should feel like hell given what he has done. It is a sad but true commentary that TV reflects our lives and that people can actually feel sorry for the man. This is what America hails as "art".

Roy said...

Well, I'm glad to see we are on the same page about this. But I wasn't trying to call you out, but rather point out how easy these subtle points of view slip into our language (yours, mine, everyone). You think it is fair that Tony gets panic attacks, but most folks wouldn't even conjure up the notion that it is also fair that he gets hypertension or diabetes or scleroderma.

My point is less the "fairness" of it than it is the brain-body split. This sense that psychiatric symptoms can be pay back, but you don't see that so much for other illnesses. I'm probably not getting the idea across too well, but I hope you all get the gist of what I'm trying to say.

My comments about being mindful of conditional compassion are probably more pointed at health care professionals, who should check their judgmental attitudes at the door (Anon's comments prove that they do not always do that, but they should strive to do so). It's similar to the attorneys who defend unsavory characters. It is an ethical issue the health care profession struggles with.

Anonymous said...

yeah, you were calling me out but you got the wrong target. funny that the words that i quoted from the blog post were not the ones you picked up on. you only picked them out in the comment section. same words.
i don't know about anyone else, but i don't buy that the people who wouldn't mind Tony having panic attacks wouldn't also wish hypertension or any other "physical" malady upon him. i would wish it all upon him and last i checked, my brain, such as it is, is in fact a part of my body so a mental illness is an illness is an illness.and yeah, i have read much about the mind/body problem. i have a couple of "physical" maladies in addition to those that go by the name mental and let me tell ya, it is like an interactive game. one has an effect upon another so i don't really understand why mental illnesses are called mental illnesses at all.
it is via the mouth or the veins or the muscles that they get the meds into you whether the meds are for the physical or mental conditions. i have to say that it is a good weapon of social control though since you can't lock up a diabetic for refusing insulin and for eating cake and sweets, meaning he is killing himself, but you can lock me up for going off meds and being suicidal. who ever held a person with diabetes down and gave them insulin against their will?
i don't get it at all. people are put in prison. some states they still have the death penalty and people support that. i don't think they would say , you know forget the lethal injection, we should have given Bundy a panic attack. i do not support the death penalty but let's be real. by the way, if Tony were a prisoner then heck let him have something for his panic. life is fair, he is locked up, i could say that in that case.

Anonymous said...

EEK, All this TV talk makes me ill. (physically not mentally) All aspects of life carries stigmas. People are people and what makes one of them a sociopath as opposed to just angry is something we have been sorting out for a long time. I think that we all have the potential for psychotic breaks and depending on what our life deals us is often how we handle these things. I happen to like Hannibal, he only killed (and ate) other evil people, please pass the Chianti. abf

Jayme said...

Wow, this thread sure got heated. Thanks for the reply, Dinah. I am looking forward to the new podcast. I am a psychiatric survivor, very much anti-psychiatry in my activism and my blog (yeah, who needs more than that?), but I absolutely love your podcast because it helps me remember that shrinks are people too. I also get a "heads up" on the latest psych topics from a shrinks' point of view. Gotta keep that mind open and free so I won't drown in bitterness. Keep up the excellent work.

Anonymous said...

EEK, est- ce que vous voulez une peu de pate avec votre Chianti?

NeoNurseChic said...

I've a few comments for this one! First thing I thought of was a speech communication class I had to take in undergrad. We all had to make speeches throughout the semester, and this girl chose to make hers on how to find a boyfriend/girlfriend or how to find a marriage partner or something like that. All I really remember about her speech was that people should, "stay away from dating people with depression because you don't want anyone like that around you." I proceded to make my next speech on depression and mental illness in general, and while I did not directly reference the girl's speech as my target and motivation, that was certainly implied. My teacher pulled me aside after class and asked me all sorts of questions - he had bipolar and wanted to know all this stuff about my own experiences with depression and different types of treatment I was going through. That was kinda weird, seeing as he was my teacher and he was telling me all this stuff, but I got 100% on the speech - I obviously hit home with the topic - although the speech was pretty decent, too! ;)

The next thing I think of is with respect to what Roy has said in above comments regarding the stigma of health care professionals. I have experienced this again and again and again as someone with chronic, constant headaches. I remember holding my tongue one night as a nurse in the ER (I overheard this while doing my clinical rotation there) said to the neuro resident, "I wish all these migraine patients would just go home." I then tapped the resident on the arm (I knew her from being in the hospital so much and also working in neuro) and repeated, "Oh yeah...I wish they would all just go home...don't you?" and rolled my eyes.

Then another night on the tele unit doing my critical care rotation..... This nurse was a pool nurse from neuro, and I was asking her about it since at the time, I wanted to work in adult neurology. I mentioned that I wanted to do adult neuro to her, and she made a face. I figured she just was burnt out from working with some of the heavier hands-on neuro cases, so I said, "Well, I really just want to work with adults with headaches." She then responded, "Oh I could never do that. I have absolutely no sympathy whatsoever for those people." I was a bit stunned. As soon as I could pick my jaw up off the floor I said to her, "Oh. I've been hospitalized here about 6 times for chronic migraine." She walked away and didnt' talk to me for the rest of the shift. Sympathy?? Those people???

The thought that goes through my mind is that I didn't ask for this. How am I different than someone who gets struck with any other random health problem?? I never did anything wrong, and yet so many times I am treated like a criminal or hypochondriac or chronic complainer just because I have headache problems. It's very upsetting. Now I've gotten much thicker skin about all of it - I don't give a hoot what most people think about it now. But even in nursing school, the comments some people would make to my face just because they thought less of me because of all this... Other people who were standing nearby when these comments were made even were shocked that people would have the nerve to say such things. At this point, I honestly can't even remember what the comments were - I think I blocked them out because they upset me so much. Because I did my honors project on improving nursing education on migraine and headaches, I had to do a presurvey to find out what my class knew, and I did a post survey after my general intervention. Some of the comments were horrendous on these!! I showed them to a friend of mine who was a psychiatry chief resident at the time, and she said, "And these are our future nurses? Oh dear..." It was pretty awful....! :(

Dinah - I thought your intentions here were very clear, and I liked this follow up post. I enjoy when you discuss psychotherapy and psychiatry in the media, even though I've never seen a "Sopranos" episode! I always enjoy your commentary and insights!

Take care,
Carrie :)

Sarebear said...

I, also, enjoy your posts including psychiatry in the media, both news and fictional.

As well as your other post topics too, of course!

I know when I'm watching a show that shows a secretary/administrative assistant in more than just a passing or one-dimensional way, that I connect with that, since that's what I used to do (and believe me, they are underappreciated, and the ABUSE I took/they take is alot more than you'd think).

I haven't seen Sopranos, but it sounds like Dr. Melfi was most definitely not a one-dimensional character, irrespective of how well she did or did not perform her "professional duties" as detailed in the shows's scripts; I don't think anyone could (legitimately) or should, fault Dinah for feeling a particular interest in this character.

Dinah said...

Thank you, sarebear!