Wednesday, January 18, 2012

The Privileged Patient

I'm still dwelling on these discussions we've had about the inpatient experience. A number of readers commented that they weren't like other patients on the ward who weren't educated, who used drugs and were in and out of jail. I took that a little personally since those "other" inpatients are my correctional patients. I like working with them and I don't like it when people dismiss them as being "just criminals." I also found it a bit ironic that the people who are quick to claim peer kinship with staff are also quick to disclaim equality with forensic patients. You really can't have it both ways. My offender patients deserve to be taken seriously, treated with respect and given humane care whether you want them in your community or not.

I don't like the idea of framing treatment in terms of who is more 'deserving' of care. I don't think you can put a rating scale on suffering or prioritize trauma. Nevertheless, when it comes to the spectrum and amount of services that are needed my forensic patients are right up there. They may not be very literate, they've got poor social supports as well as mental health and addiction problems. Oh, and chronic medical problems that go untreated because they have no insurance. They're facing an uphill battle just to reach a "normal" place in society. For my patients, success means having a place to live, a job, people who care about them, maybe even a car and a girlfriend. That's a lot to have when you're starting at zero. Yet when it comes to apportioning services and access to treatment these are the first folks to get cut.

Some inpatient units do have patients of privilege---people who aren't starting at zero---and these patients really do seem rich (figuratively and literally) in comparison. But forensic patients are increasingly part of our mental health care system. When we talk about making the system better they have to be part of that discussion.


Anonymous said...

Mental illness and addictions do not discriminate.They hit people who are educated and people who are not, all races, all levels of the socioeconomic status etc. Some people commit crimes that land them in jail. many of those people have something for which they should be treated if they so choose.I did not read any post that suggested that the prison population was undeserving of treatment or of humane treatment. Many of the people in prison would not have ended up there had they had better diagnosis and treatment to begin with. That said, I do object to the way in which mental illness itself is criminalized such that even a non violent individual is cuffed, thrown into a cop car and dumped in the psych ward as well as being left with a police record merely due to the police escort that was necessary because we lack the funding for paramedics to deal with people who need to be hospitalized for mental illness. if the police took a heart attack patient to hospital because they were first on the scene, the person would not have a police record and if you are dropped off at ER by a random person, you also don't get one.
I know of some doctors and lawyers and financiers in prison. They are pretty well educated people. They may or may not have an illness but they are committed crimes. I know that in the times I have been hospitalized, I have shared living space with people who were doctors. lawyers and financiers as well as with people who did not finish grade school or who did but were on social assistance and had zero in terms of money, social supports, place to live.
On the psych unit, no one cared who had what degree. We were all there in our hospital garb and patients were generally very supportive of one another no matter what their background.
I did not get special treatment because of my degrees. i did get special treatment at the hands of the police because I have an illness. The latter is what i object to. As for peers, I shared a room with a few other people. Inside the hospital, we had a common bond. We all hated the nurses who treated us like human waste. We were such a diverse group of people that there is not a great likelihood we ever would have sat down together for a coffee has we met on the outside.Peer is defined as people who have equal standing. I suppose that as fellow inmates of a psych ward we all had equal standing in that regard. I do not care who other people decide are my peers but it is true that on a psych ward even a doctor patient does not have equal standing with the doctors running the unit. If you walk into a nursing home you will find people who were once doctors or professors or rocket scientists and you will find people who were once brick layers and bar tenders. You could decide that they were all just old folks and that as such they held equal standing. One day we will all be dead. The great equalizer will make peers of us all. Like I said, I don't much care who other people designate as my peers on this earth but i wonder how many docs consider psych patients their peers until they end up in restraints themselves. I doubt that prison shrinks consider themselves the peers of the inmates.
Oh, the person in the graphic is also not my peer, no way, no how.

rob lindeman said...

"I don't think you can put a rating scale on suffering or prioritize trauma."

I think you can.

The soldier who shoots himself in the foot to avoid going into battle?

The adulterer who presents to his urologist for erectile dysfunction so that he can perform with his mistress (true story)?

The couple who presents to a genetic counselor to obtain pre-natal sex determination so that they can terminate the pregnancy if the fetus is female (also a true story)

I know, these cases are different. My point is only that physicians can and do draw moral distinctions between clients. It's only human to do so. And I would argue that we physicians ought to stay true to our human nature.

wv = falua; bizarre Indonesian sexual practice, now viral on the web

Sideways Shrink said...

I can't guess what your interpretation of "staying true to human nature" is. We don't and can't do comparative pain and suffering in psychiatry. Because all humans make discriminations between other humans as per learned values based on social positions determined by gender, race, religion and class among others does not mean that we should continue to make them in an unexamined way. Upon examination, we can ask ourselves whether our pre-judgements are true or are based on the real characteristics of our patients or others we think we understand.
I think all trauma is trauma. A Vietnam veteran is no more or less traumatized than a Hmong tribesman refugee or a Cambodian immigrant--regardless of whether the immigrant's child was picked up on a drug charge and deported back to Cambodia (which I can say is not a picnic 35 years later).
A woman is raped in childhood multiple times by her father, brother, or her uncle--is that more traumatic than a date rape in college or more traumatic than being raped by a spouse out of "no where" or more traumatic than a rape by a soldier at gunpoint?
Oh, these are the extremes of why there is no comparative trauma in psychiatry. "Human nature" is infinitely changeable. If it weren't what would be the hope for any of us as people, let alone as health care providers?

Anonymous said...

LOL, as if the docs on the units consider the nurses to be their peers or the nurses consider the orderlies to be their peers. Do you think that the hospital staff see themselves as one big peer group by virtue of the fact they work in the same place?

CatLover said...

I was upset about some of that discussion also. I had serious concerns once about a patient who talked a LOT about violence with guns, but he saved his anger for the staff, who was aware of the problem.

You know, you can usually find something in common with another - you can talk about cats or dogs, or someone's kids, or how the football team is doing, or how hard it is to eat your breakfast sausage with those plastic utensils they give you, etc. Is it going to kill me to play crazy 8's with someone because they can't play cribbage? when I'm inpatient, my cribbage game is bad anyway.

Anonymous said...

Thank you for this Clink. It reminded me of one of the few good things about my incarceration, my fellow patients. We ranged in age from late teens to mid-70s, both genders, many different races, ethnicities, religions, educational levels, etc. Some of us were college educated. Some of us were mothers. Some of us came from jail. Some were business people. Some were homeless. Our diagnoses were all over the map as well: depression, bipolar, PTSD, schizophrenia, anxiety, drug/alcohol abuse, panic attacks, BPD. But all of those differences ended up being superficial; almost all of us became friends during our time together. And that was really nice.

Sunny CA said...

I have no idea who the other patients were on my ward, as it was considered a violation of ward rules to talk to other patients except during supervised visits to the cafeteria for those close to release. Saying "good morning", accompanied by eye-contact and a smile to another patient was considered "manic" behavior, so we had to keep eyes down and not look at or speak to other patients in order to be viewed as "normal". I have no idea who the patients were or what they did when they were not in the hospital.

I did have the experience of being treated by the staff as though I was non-working and lived under a bridge, however. I do not "look down on" people who are not capable of working or those who are in hard circumstances and live under bridges, however, my reality was that I owned my own business, made a better-than good income and lived (and still live) in an upscale area in a fully-paid-for single family house. In group therapy (the only type of therapy offered), however, when I said "I am a wedding photographer", the person leading the group said "Yeah, right. SURE you are." I insisted that I was a photographer and gave specific details to try to prove that I was in fact a photographer, but my response was considered to be a further indication of mental illness and that I was not ready for release. I was flat out not believed regarding my "regular" pre-hospitalization life. To me that is a prejudice of the staff, that they think patients who they are treating are incapable of working and living a normal life. Just because I am not prejudiced against homeless-non-working, does not mean I want to be thought to be homeless-non-working and not believed about my actual life. I learned that what I needed to do was to go along with whatever their opinion about me was if I wanted to get out of there. That is not the way to help people become "sane". The staff also did not believe I had not been on psych medications previously. They did not believe I had never had a previous hospital admission or previous "breakdown". I finally played the game they wanted me to play, because to do anything else would prolong the hospitalization. Being in-patient was pretty close to having fallen down the rabbit hole (al la Alice in Wonderland) and finding yourself in the Queen of Hearts court. Instead of "off with her head" they have the power to say "Off to ECT" and multiple times daily medications are either "voluntarily" taken under supervision or forcibly given. In the end, if they want you to stand on a line for an hour and a half with hands at your side, 10 feet in front of the nurse's station to ask a question, you do it. If they want you to not discuss that you worked up until the day of admission, then you do that. If they want you to avert your eyes and not greet the other patients, then you do that. Wanting them to believe me about my existence has nothing to do with my personal prejudice against other people's lives. It shows staff prejudice against patients.

Anonymous said...

Yup Sunny, that is how the staff reacted when they asked me what form of social assistance my family was receiving. When i answered the question with "no form of social assistance benefits", i was asked how I fed my children. It was tough for them to imagine the diversity of people in their "care". if you need assistance, that is what it is there for but why do people assume that only poor people get sick? i think it is because the truth is that the staff are not living on social assistance and they need to convince themselves in any way possible how much different they are than the patients.

rob lindeman said...

"'Human nature' is infinitely changeable."

I don't agree, but the question is beyond the scope of Clink's post.

My point is much more prosaic, and that is that we can and should exercise moral judgment when we practice medicine. The capacity to make moral judgments is a feature of our (unchanging) human nature.

Kate said...

Clink, you're not interpreting what I've said accurately.

I didn't feel that I was better, smarter, greater, funnier or any other positive descriptor more then the patients who were more similar to your correctional patients. In fact, I became friendly with all the people (bar one or two violent folk) on the unit and we spent hours and hours and hours over long holiday weekends talking, laughing, playing cards. I liked a lot of them a lot, just as I liked other non-correctinal patients a lot. I don't disrespect them and I don't for a second think that they don't deserve human care. Where did you read that?!??

That said, I also did not relate to them in terms of discharge planning, professional goals, outpatient support systems (both professional and personal) or even homelessness.

I did not relate to being angry enough to become violent and hurt other people - not just talk about it, not just think about it, not just feel it, but do it. I could not relate to someone who really did not comprehend any other option.

I did not relate to having no one in my life who cared about me because I had alienated every single one of them over and over again for decades.

I did not relate to not knowing where I was going to sleep the next night because I was unable to hold down a job and pay my rent.

I did not think any less of your patients, Clink. But I did resent that 90% of all discussion and conversation in 90% of formal group and informal staff-run gatherings had to do with the above topics - violence. homelessness. lack of family/friends due to alienation. I didn't think any less of them. But I deserved to have my concerns addressed as well; it was my treatment, too. I was being treated for severe depression and was hospitalized for suicidality.. Not for personality disorders. Not for violence. Not for medicaiton non-compliance. Not for lack of outside support.

I deserved to have my concerns addressed as well, as did the other people who were "like me," aka had professions/careers/family support. It doesn't make the other people any less. I didn't think any less of them. But I wish that my issues had been addressed, even once. Why should I have to sit back and listen to constant talk about jail, violence, homelessness, etc in therapeutic groups? Why were my very real concerns the ones to fade? That's not fair, Clink.

It is absolutely not about deserving. Everyone, EVERYONE, is completely deserving of that care. Your patients are starting from way behind the starting point of me and millions of other people ,but that doesn't mean that they don't deserve care. However, care should be given in a way that benefits all. It is not dissimilar from school systems: children with severe disabilities deserve education just as much as those who are typical and those who are gifted. However, shoving all three rgroups in a room merely creates chaos. All of the students - normal and not - need - and deserve - to be groups according to need, so that they can receive the education best suited to them, on their level. The education that they DESERVE.

There needs to be a better system, so that people can learn and gain from each other. Not sit frustrated, miserable, (and at times frankly scared) because talking about jail, violence etc must be the norm. Just as your patients deserve care that meets their needs, I deserved care that met mine. I'm sure they wouldn't have been thrilled to hear all about my worries for my PhD and my future profession and construction on my house and my young children and visiting parents. But they didn't have to sit and listen to it over and over again, because I never had a chance to say a word, because it was non stop, for 16 days, in every single group, in one of the top ranked hospitals in the US, all about jail. homelessness. alienation. Every single one.

Why is that fair, Clink?

Alison Cummins said...


Fascinating. It's never appropriate to treat irrational, psychotic people against their will (although it's perfectly fine to imprison them against their will).

Now you're saying that it's ethical and professional to withhold care just because you feel like it.

A moral sense is more id than anything else. There's nothing wrong with having an id, but we have superegos for a reason. In this case, professionalism dictates that one offer care to a patient, including for sexual health, even if they are making choices you would not.

Some people have strong feelings of disgust and modesty. Others do not. Those who do experience them as fundamental laws, but they aren't. They're just feelings. If I need health care, professionalism dictates that you refrain from making me justify myself to you to get it. An ER doctor cares for many people who make the kinds of choices that the doctor - someone who has the motivation, discipline and cognitive skills to get through medical school - would not. They might feel sad when an injection drug user shows up needing treatment for an abcess, they might hope that their own child is never in that situation, but then they go ahead and offer the care their patient needs.

I don't find the notion that a man might have both a mistress and erectile dysfunction at all strange; I believe it's quite ordinary. I don't know why you find it so exceptional, and neither you nor any doctor has any business withholding medical care from patients in an attempt to control their sex lives.

Anonymous said...

Kate, sums up my thoughts exactly. I wasn't saying I was superior to other patients. I am simply saying we have to address individual needs. For example, it's a complete and utter waste of time and resources to have patients who don't self harm sit in a group about self harm just because that happens to be the group topic for the day. It's like sending all patients, regardless of their injury to work on their legs in physical therapy. If they have a problem with their arm, they work on their arm. If the patient doesn't self harm, then why are they going to that group? They had a woman with Alzheimer's attending, a person with mental retardation, etc, none of whom self harmed. What is the point in that?

Incidentally, why do they have professional programs for physicians in distress? I would assume it's because there is a recognition that they need a different approach perhaps? I can't think of a single physician I know who would have sat and pretended to be animal in a circus or other goofiness the psych hospital passed off as treatment. It has nothing to do with being a "privileged patient."

I am curious, though, why mental health professionals use the terminology "peers" to describe patients when no other area of medicine does that. Does anyone know?

Anonymous said...

Psych patients are called peers because we get report cards the way children get them. "plays well with peers" or, has difficulty sharing with peers".We are treated like criminal children, actually, that is why.

Dinah said...

One of the things I'm struck by is the diversity of experiences people seem to be having. Clink throws out a post, essentially 'please don't dis my patient' and some people come back with 'exactly!' while others come back with really good reasons why it's fine to for different folks to have different needs. One person says they weren't allowed to speak or make eye contact with other patients, another says they played cards and shared stories in a meaningful way. It seems that psych units differ greatly with respect to mileau, rules, kindness of the staff (and some until that have mostly kind staff may still have a loser here or there), quickness to search/medicate/and seclude, and the degree to which patients feel they are believed and validated.

I think this diversity of experience makes the discussion hard sometimes as we may tend to generalize. I know I do, where I trained I'm sure there were unhappy patients, but the unit was new, with carpeting, pay phones, edible food, regular visiting hours, and a department chairman who would have bounced you to the moon for disrespecting a patient. We didn't dare carry a cup of coffee on rounds, we stood when a patient entered the room, patients were addressed by their last names, and every service rounds/grand rounds or patient presentation began with the chairman asking the patient if they were being treated kindly by the staff, so yes, this colors my perceptions, and thank you all for sharing different experiences with me. That said, if you were a patient, it would be unwise to be wearing a shirt with an obscenity on it (no hospital gowns, except maybe in seclusion rooms).

Anonymous said...

When possible, inpatient treatment groups should be segregated by social status. An overly-heterogenous group is not ideal in group therapy. It's unfair to the minority social status group member (and this works in either direction) to have the group's topics have no relevance to their circumstances. Someone with a education, profession, and no criminal history is not going to do well in a group full of homeless ex-cons. The converse would be equally unfair. Groups should be as homogenous as possible to be effective.

ClinkShrink said...

Jessa, Kate, Teufel, Anonymouses (?Anonymi?):

Thanks, I'm glad you all agree that my forensic folks deserve equal care which was really the point of my post. The risk of feeling 'they're not like me' is the subtle slide into 'so it's OK to treat them differently.' The analogy to students of differing abilities is apt, and I've followed along historically as people have disagreed about whether disabled students should be put in 'crippled children's schools' or kept in regular classrooms. Ah, but not every public school has advanced placement classes or gifted and talented programs. And Anon, good point about hospital staff not seeing each other as peers. So true.

rob lindeman said...

"'s perfectly fine to imprison them against their will" IF they break the law. Being psychotic isn't illegal (is it?)

The relationship between erectile dysfunction and psychiatric nosology is compelling. The former became a disease only when we named it. Prior to FDA approval of phophodiesterase inhibitors for impotence (the old name), ED didn't exist. Similarly, psyche diagnoses become reified when a panel of so-called experts writes a consensus statement. This is the same mechanism by which psyche diagnoses go away (see "Homosexuality")

The duty to treat is not absolute. For example, I am under no obligation to prescribe Amoxicillin for a child with acute Otitis Media, when in my best judgment doing so would be more harmful than helpful (with the backing of the evidence base).

And it's a bit of a stretch to suggest that a doc can control a man's sex life. Refusing to treat a person who is not in acute distress (unless you define wanting to boff one's mistress really badly 'acute distress') is not a breach of ethics.

wv = laverio; very small toilet

Anonymous said...


I keep looking for your name when I go to prayer services but it never comes up. Oh my Rob, when will you get off your high horse? Oh, and thank you for my daily bread, i mean laugh.

rob lindeman said...

That's odd, I've seen YOUR name (anonymous) in prayer books!

Anonymous said...

That is correct, Rob. I wrote the Gospel of Luke. I write the songs that make the whole world sing. No wait, that was Barry Manilow.

Sideways Shrink said...

THAT made laugh. I am always confusing myself with Barry Manilow. Thank you.

Anonymous said...

Rob writes, "'s perfectly fine to imprison them against their will" IF they break the law. Being psychotic isn't illegal (is it?)"

I agree. I think when an adult breaks the law and is arrested it doesn't come as a surprise that they lose some of their rights - they are strip searched, incarcerated, etc. They should still be treated humanely, but the strip search, etc is expected.

I think there is also a reasonable expectation that when a patient is hospitalized, has not violated any laws, that they should retain the same rights and privileges as any other adult patient, including not being subjected to being forcibly stripped. Luckily they didn't carry it further and include a body cavity search, but I was certainly afraid they would.

Anonymous said...

Clink writes, "Ah, but not every public school has advanced placement classes or gifted and talented programs."

I don't see how that compares to treating patients in psych hospitals at an elementary school level. Is the argument lack of funding? Because if it were truly about lack of funding then they wouldn't require people to have treatment that they don't want, didn't ask for, and don't need. It would seem that if there's lack of funding, then there would be more focus on using resources wisely - like incorporating some of those inexpensive suggestions mentioned in previous posts - enourage what is helpful to each individual patient - reading, writing, watching tv, playing cards, sitting in the sun, attending groups if they find them helpful, and skipping groups if patients don't find them helpful and/or they don't pertain to a patient's particular issues.

I also don't see how they can bill the government for giving people treatment they don't need - like the woman with Alzheimer's disease who doesn't self harm sitting in a self harm group. That sounds like healthcare fraud to me.

Anonymous said...

And...Dinah has a "yes...but" once again. Your experience as a resident 15 years ago is irrelevant. In fact, even the experience of current residents is irrelevant. It is what is then transmitted/occurs on the unit that is relevant here.

Do you "yes but" and have a justification for your patients all the time too?

Anonymous said...

^ probably, and they don't care because they have a celebrity shrink. C'mon, you think Oprah is smart??? This is no place to come for intellectual discussion. Makes me wonder why Rob bothers at all. He is usually way out there, but smart nonetheless. i wonder if he comments between patients. Oh, Dr. L is running late. LOL. Dinah is my nightmare shrink. i would rather go to jail.