Wednesday, March 06, 2013

My Patient Is Not A Peanut Butter Cup

On CBS news yesterday I saw this report about mentally ill people who end up in jail. The sheriff of the Cook County jail complained that psychiatric patients who don't take their medication become criminals and added, "We're not a mental health facility. These people should not be here.''

Simultaneously this week in the Baltimore Sun we have this story, where hospital workers complained because malingering criminals were being held at their facilities.

This week's news is a terrific example of what I call the Reese's Peanut Butter Cup problem of forensic patients. (I put up the old commercial for reference.) Each side is basically complaining that they have to provide care for someone. Nevermind that people can't be cleanly divided between the "mad" and the "bad," or that people who "only" have personality disorders can still die from those disorders. We waste a lot of time and energy arguing about who should be where and who should be doing what.

The bottom line is that we have to figure out how to deliver the right care to the patient regardless of the setting. Forensic patients require treatment as well as security. That sheriff needs to realize that his facility will always require a psychiatric infirmary and mental health services and that he's not going to be able to "clean house" off all the psych patients. Similarly, hospital workers can't write off every assaultive patient as being "just a sociopath."

We need to beef up hospital security so everyone, patients and staff alike, can feel safe. And jails need to be given enough mental health staff so the administrators won't feel like they're being overrun with chaos.

Getting rid of the patient is never the right answer to a health care system problem.


jesse said...

"You put your chocolate in my peanut butter," she coos in mock protest. Clink, I think you are too young to get what they are _really_ talking about. That ad sold a LOT of Reese's cups.

Yes, there is no way to separate the two populations. The jails need to give better care to the ill, and the state hospitals need better support. It all takes more money, and there's the rub.

jesse said...

A further thought on the rejection of "psychiatric patients:" much of it seems to come from people not seeing psychiatric patients as being like them. They are too uncomfortable with the possibility that someday they themselves, or someone they love, might be a psychiatric patient. This is not true with all sorts of other medical illnesses, and is partial explanation of why the funding is so poor.

Even though we are all aware of the fragility of our bodies, and understand we can be struck by many terrible illnesses, our minds seem totally inviolate, permanent, and under our control.

Anonymous said...

"our minds seem totally inviolate, permanent, and under our control."

That is interesting. How many people feel they are in control in their dreams?

That question has three aspects. How many feel they are in control of their reactions in dreams? How many feel that their memory works properly in the dream world? And how many feel they are in control of the content of their dreams, i.e. of their full minds?

Regarding the latter two questions: if people's memory worked properly during dreams, then as a rule they would know they are dreaming. And if they were able to influence the content of the dreams, they would also know they are dreaming, usually a sign of waking up soon.

But people don't usually know they are dreaming. And sometimes when they know and try to wake up, as from a nightmare, they seem trapped in the dream world.

The inevitable conclusion is that everyone has experienced rather tremendous lack of control regarding their own mind, their reactions, intentions, memory processes, "perceptions", and so on.

So no offense but the idea that we are in control of our minds, an idea I agree seems popular, is definite proof of either serious deficit of rationality on the part of humans, or of their not being "in control" of their conclusions and all that that entails even while awake.

How can anyone fail to draw the obvious conclusion that there's nothing unusual in not being in control of one's own mind? I think that's the mystery the researchers should be solving, before they try to solve how come the dream world can in some cases invade the waking world. The solution might provide some clues to our predicament, as would solving the mystery of seemingly impossible synchronicities.

Anonymous said...

"How can anyone fail to draw the obvious conclusion that there's nothing unusual in not being in control of one's own mind?"

'My' subconscious informed me just now that the psychiatrists have a vaguely plausible answer for everything, in this case: compartmentalisation.

Would sounds like this in this case: That's just my dreaming self. In the waking world I'm completely in control, so this means I'm always completely in control and can't relate to anyone who isn't.

Still mad though.

jesse said...

@mctps: I think you've got it. What I was saying is that while most people would easily acknowledge they could get cancer or have a serious accident, they don't consider they could come down with a mental illness. So the funding for it is often an afterthought.

Apropos of what you have been exploring, though, it has often been said that mankind has suffered three large blows to its self-importance. Copernicus showed we are not the center of the universe, Darwin showed we are not separate from the animal kingdom, and Freud showed we are not masters of our own house.

And as Clink has just shown, our mental hospitals cannot be kept strictly apart.

ClinkShrink said...

Jesse: It's been a long time since I've been accused of being too young for something! But thank you.

Yes, it costs money to do this stuff. The thing about institution-based care though is that eventually it costs more money not to, and that fact can be leveraged to provide more services. A facility under court order to beef up treatment can be given a daily fine for failing to comply, and eventually a tipping point gets reached where it's just better to go forward and fix things.

Unfortunately, free society has no such leverage. It is more costly to society over the long term to not provide treatment, but no mechanism to hold a single entity responsible.

Anonymous said...

'getting rid of the patient is never the right answer in a health care system' - i wish this were a true statement. it's not a right answer, but it is a true answer, if you know what i mean. mental health diagnoses still carry lots of stigma, and discrimination - even with supposed 'parity' of insurance coverage and understanding of the biopsychosocial model of illness.

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m.w said...

Maybe more money spent on scans such as PET scans would help us to distinguish who is pathologically violent vs who is truly evil and wilful? I think people who are evil-ie:fully know what they are doing is wrong belong in jails and that there should be separate forensic hospitals for those who commit acts because of pathology,and thirdly that there should be regular mental illness homes for those without criminal histories & that the three should never mix.Though,distinguishing who belongs where is much easier said then done.