Friday, June 06, 2008

But I Do Want To Talk

First, Roy wants your opinion about Online Access to Prescription History, so if you haven't chimed in, please do.

This post was inspired by ClinkShrink's post, I Don't Want To Talk, where she discusses mandated debriefing after trauma and what role that might have in either preventing or causing mental illness (Roy: which is what we spent all of podcast #46 talking about).

Disaster Psychiatry is a field that it still defining itself. It's a close-to-home issue for me because Shrink Rap was started as a way for me to deal with some residual angst I had after returning from a couple of weeks in Louisiana where I worked on the Katrina Assistance Project. Roy & Clink got sucked in, but what can I say? At that time, I wrote a piece about my experiences and posted on it's own blog link. I talked a bit about the stuff ClinkShrink discusses-- some history of the Mitchell Model of Critical Incident Stress Debriefing, as well as Sally Satel's paper on how the mental health industry exploited the terrorist attacks of September 11th. You can click HERE to link to my Katrina Reflections.

Since ClinkShrink wants to talk about mandatory debriefing and whether talking about a trauma lessens it's impact and prevents the development of future psychopathology, I'll talk about my own thoughts about the role of psychiatry in the aftermath of a community
trauma.You can define community in a big or small way, but I mean a shared experience as opposed to a traumatic act to a single individual .

There are five concerns from a shrink's point of view. There may be more, but these are my random thoughts and it's our blog. Do chime in on the comment section.
  • There are people with psychiatric disorders who may no longer have access to treatment-- perhaps because they need to relocate, because their doctor &/or records have been obliterated, their pharmacy closed down-- and they are at risk for a relapse of a pre-existing illness.
  • There are people who develop psychiatric disorders as a direct result of stress-- it's not unheard of for people to become manic after the death of a relative, to become anxious or depressed, and so if psychiatric symptoms are precipitated without disasters, it's safe to assume they can be precipitated by trauma. Certainly, some of these people may have underlying disorders that would eventually be unmasked anyway.
  • There are people who develop psychiatric disorders as a direct result of the specific trauma who may not have ever required the services of the mental health profession if such an event didn't occur. The question here, and the one that ClinkShrink addressed, is whether early interventions to the entire population alter the likelihood that someone will develop a psychiatric illness. Who to target, what to target them with, and if it will matter are all questions to address
  • There are people who are distressed by an objectively distressing event but who don't (and hopefully won't) develop a psychiatric condition. These people often feel a need to talk and are well-served by friends, family, and religious leaders. The role for psychiatrists here is one that should be taken only if the trauma victim identifies himself as a patient and requests treatment. There seems to be a statement in our society that it's bad to not talk about troubling things-- this is true for some people who feel a need to talk, but it's a blanket statement that often crosses the line into being judgmental.
  • Lastly, there is question as to the role mental health professionals should take with disaster workers who go to the aid of the victims. We're back to the Critical Incident Stress Debriefing and I wonder if the issues are different for those who are in the position of being helpers voluntarily (Red Cross workers and assorted humanitarians) versus those who go as a job requirement-- fire fighters and the like. I'm not sure what to say here. Again, this speaks to the issue of interventions to prevent the development of disorder in a population that might remain healthy without intervention.
Ugh, I can't get a picture in. Open all those alligator mouths and yap it up for me.


Anonymous said...

Nicely written. I've had a chance to read the pre-publication copy of the study I blogged about in "I Don't Need To Talk". One of the interesting things it showed was that even for people who generally use venting as a coping mechanism, they did better longterm if they chose not to vent in the acute phase. This was true even after controlling for personality factors (extroversion, etc, the Big Five). This would probably be a good podcast topic.

Midwife with a Knife said...

clink: could there be a confounder there? What if people who didn't feel the need to talk are the ones who, originally, are less traumatized by the event or undergo less traumatic events? It's hard to standardize degrees of trauma for research.

Doc said...

Many PTSD studies in the military show an inverse ratio between the proximity to the trauma and the likelihood of developing PTSD. It seems that those who were able to be very close to the trauma, were less likely to have PTSD symptoms. I imagine that it had to do with the ability to do something about it at the time (e.g. shoot, hide, etc.).

An interesting study would be to analyze the willingness of people to talk for all those who were forced to attend debriefing vs. their long-term outcome.

Having been distantly involved with the community tragedy here in VA (the shootings at VA Tech), I can state that regardless of the current data--or lack thereof, mental health support should be universally available. Whether by job or volunteer probably doesn't make much of a differene in the long run, I imagine.

It is also important for mental health experts to be present at the community and political level after the fact, to help dispel myths, assist with recommendations of care, and with preventive planning strategies.

Anonymous said...

This was a pretty remarkable study both for the number of subjects as well as for the gajillion things they controlled for. The variables included measures of acute symptoms, past medical & mental health history, number of previous traumatic events, distance from the WTC, level of exposure, personality traits as well as demographic characteristics.

The people who were most likely to respond to an emailed invitation to vent about the trauma were older folks who lived farther away from the WTC. Regardless of the above-listed variables (to the best of my recollection) the folks less likely to develop later mental health or medical diagnoses were folks who didn't vent acutely, even the extroverts.

I agree with Dinah's observation that the non-venters could have been venting in real life rather than through email.

Doc: I think the main controversy is over the timing of the intervention (acute versus remote) and the purpose (prophylaxis, which may or may not work) or post-onset, as Dinah mentioned in her Katrina experience. Mental health services are certainly going to be needed eventually, it's just a question of when and for whom.

Mom said...

I was part of the group of mental health professionals in my city who volunteered to provide free care to anyone who wanted it related to 9/11. No one came to me. Nor to any of my colleagues.

Nikki said...

Can any doctor please tell me how bad medical school is? I'm scared I am going to work so hard to get in only to hate it, have no life, and be counting down the days until i can get to my psychiatry rotation and be happy (the only type of doctor i really want to be is a psychiatrist). Any thoughts from any med school grads?

(I'm not sure if people are supposed to ask questions in comments, but I would appreciate any responses!!)

Anonymous said...

"The role for psychiatrists here is one that should be taken only if the trauma victim identifies himself as a patient and requests treatment."

I absolutely agree- if someone doesn't want to discuss something then to insist that they participate in a debriefing is inherently demoralizing and dehumanizing. It presents the impression that because the individual has been exposed to an unpleasant experience beyond their control that more control is to be taken away.

"There seems to be a statement in our society that it's bad to not talk about troubling things-- this is true for some people who feel a need to talk, but it's a blanket statement that often crosses the line into being judgmental."

There seem to be two camps on this. I work in a field where seeking mental health services is still frowned upon and can have adverse repercussions on careers. At the same time, I know that in general friends who have chosen other fields assume that everyone will be in therapy at some point and those that aren't are afraid of it and therefore need it all the more.

Lastly, I think there is a strength one can experience from having survived a horrible ordeal or life threatening event. I would guess that people who are not venting are taking other positive action- positive being doing life affirming things- which I imagine will help mix the memories. If you spend a lot of time venting and reliving an event early on I imagine the memory becomes stronger, more vivid and detailed, though not necessarily more accurate.

a psychiatrist who learned from veterans said...

My limited acquaintance with this literature supports clinks view; debriefing, from a mental health viewpoint, is a bad idea. Ultimatley, one should (mentally) add a line to Eccelsiastes: 'There is a time to talk and a time not to talk.' The problem is that PTSD is, in one perspective, overlearning and debriefing supports overlearning, aka 'intrusive thoughts,' being trapped in the trauma. As I noted in my blog, the best paper in recent years on PTSD is that of Aernii et in Biological Psychiatry which showed that 10 mg of hydrocortisone for a month could lessen the patients 'overlearning' of traumatic memories.

Roy said...

Hey, shrink-who-learned-from-vets, be sure to listen to podcast #46, where we talk in detail about Aerni's paper and the other one from Cai that you had mentioned. I think you inspired the entire podcast (except for maybe the Flomax).

Sara said...

Nikki - if you already know what you want to be and are sure, med school could be a lot easier because you can just coast through everything else.

And except for the first classes with the chemistry and anatomy, I had a hell of a lot of fun in med school. Exam time sucks, but the rest of it is what you make of it. Find the people around with a good sense of irony and who aren't too intense about grades (ie the future family docs, psychiatrists, gynecologists) and it can be hilarious and fun.

Anonymous said...

I was raped with a knife to my throat when I was 19 years old. I told nobody at the time because I feared my parents would find out if I did tell (and I feared my parents). I went through a few days of shaking then moved on with my life. I had 4 therapists along the way who I did not tell but FINALLY talked about it with my psychiatrist when I was 56 years old after months of getting to trust him and finally feeling that I could talk about it with him.

In my case nobody knew what had happened, but I COULD NOT talk about it at that time. I really needed a trusted relationship with a psychiatrist, plus perspective on my birth through age 19 years in order to understand what happened and my reaction (lack of reaction) to it. I suspect if I had been thrust into the care of a trauma specialist I'd have had a hard time with it. Perhaps the right person could have gotten through to me.

I have changed. NOW I would WANT to talk about any trauma that might happen to me, though I would still want it to be with the psychiatrist I trust. If an earthquake struck, though, now I'd be able to talk to any mental health professional if I had no access to my psychiatrist.

Anonymous said...

Psych Vet: This is why I get concerned when my vet patients tell me they went through mandatory debriefing after they came back from deployment. I wonder how many people we're inadvertently harming for the sake of providing a treatment that's politically popular.

Awake and Dreaming said...

This is been fascinating to read and has really prompted me to think about my own reactions and responses to perceived trauma. Because I think that's important to remember; what i perceive as traumatic will be traumatic for me, I don't need someone to tell me what trauma is. I remember when I was in therapy, and I would tell my therapist about the latest crazy event in my life, someone dying at work or whatever, sort of cause I felt I had to. She'd ask if I wanted to talk about, I'd say no, and we'd move on.

Times I've had bad experiences and really wanted to talk about them, there never seems to be anyone around. I usually find that by the time I find someone to talk to, I'm okay with things a little more, and I can think through things instead of just venting. That being said, I write, a lot. I journal, I blog, I work on my book... and I blog in my head, it sounds crazy, but it helps me think. So I have ways of getting things out.

I think that's one of the great things about the way we do our "mandatory" debriefing after Street Outreach. You can talk if you want, but you don't have to, and you can share good stuff or not, there's no pressure. And no one cares if you bring up something from a month, or a year ago, that's troubling you now. I totally support that style. I mean, you still have to listen, but it's a no pressure thing.

So, I don't know what I think about the whole subject. I think it's very worth further study though. And, I know then when people make a big deal about something, it often turns into a bigger deal then it was.

Rach said...

Ahhh. I have a ton to say on this subject... I'm overseas volunteering as an EMT in the middle east, and I'm seeing this both in the civillian and military populations... I'm going to come back to these posts when I'm home in mid-summer...

Anonymous said...

On a tangentially related note to one of the above comments - as a speaker of British English, whenever I see "vet" I think veterinarian, not veteran. So "vet patient" makes me think of a psychiatrist earnestly counselling a guinea-pig. I like our way better - we abbreviate the longer word to vet, rather than the shorter word. :-)