Saturday, June 15, 2013

Shrinky Stuff Around the Web

Today, I'm just going to point out some links by others who are talking about the same types of things we've been talking about here on Shrink Rap.

Regarding everyone's favorite topic, involuntary treatment, Dr. Greg Smith talks about his experiences committing people at Are You Ready to Commit? 

On the Huffington Post, Erin Hawkes writes Medicate Me Even When I Refuse.

And Pete Earley talks about the safety of tasers in Tasers: Friend of Foe

On the topic of privacy, PsychPractice wrote a post for me defining HIPAA.  See What, Exactly is HIPAA? 

And while Rob has talked about how he does not like it when chronic mental illness is compared to chronic medical illness because we don't know the exact physiology, PsychPractice has a blog up about the politics of defining Type II diabetes, which is surprisingly similar to that of determining the criteria for psychiatric disorders.  See Learning from Diabetes



Anonymous said...

I've read a lot of Dr. Smith's blog, and he seems like a very kind person. I, too, wonder about those who are not committed who go on to commit suicide, because I came very close to being one of those people in the years after my involuntary detention.

I wonder if there is a way to reach people who keep quiet because they know if they share the depth of their darkness the result is that they will be forced once again to take off all their clothing, stand naked trying to cover their bodies as nurses catalog their belongings. I wonder if they remember that sharing the thoughts in their head meant ending up behind a locked door, wondering what would be done to them next, wondering why opening up their wounds means they will have to hear the click of the door closing them in playing over and over in their heads for months after discharge. I wonder if they remember the days after discharge, increasingly agitated, fearful and alone, making plans, and telling no one.

I wonder if there is a way to reach people who are in this darkness struggling alone feeling like they have to choose between incarceration which made them more isolated and afraid and putting a gun in their mouth. I wonder if a psychiatrist could find a way to work with them as my therapist and psychiatrist did, where they can finally share all of this despair without fear.

I think it is when I learned that I could not be honest about the depth of my darkness, that they are I was most at risk. It is when I was not talking that the plans were actually being made. I needed to be able to talk about all of it without fear of being further traumatized. I am so incredibly grateful that my therapist and psychiatrist took a risk with me, because they enabled me to finally unload all of it and begin to work through it. I remember the first time I met my current psychiatrist. I barely said two words to him. He knew, though what I was dealing with, because my therapist told him. He responded with such kindness. He told me as I was leaving, "I know you have been suffering for a long time, and I'm going to help you." And, help me he did. With the right medication and a whole lot of support, I am finally free of this despair I lived in for years.

I do understand that there are people who have been saved by forced treatment, but I think we have to also think of those who have stopped reaching out for help. Maybe we can reach them, too. I believe we can.

Pseudo Kristen

Sunny CA said...

Dr. Greg Smith's article makes it seem that the decision to commit is always obvious, and I guess if it is that clear, then commitment is the logical step to take. It strikes me that there must be many more situations, that are less an end member in the continuum of mental health, and the decision less obvious.

Erin Hawkes is also an extreme case, in my opinion. Not everyone who ends up involuntarily committed feels like rats are eating their brain, thank Heavens.

Regarding Tasers: It is usually less damaging to be Tasered than to be shot with a firearm, but if there is a high enough percentage if deaths, then maybe the power of a Taser should be lowered to the lowest effective level. Overuse of Tasers is an issue of police training and judgement. When police are called about a psychotic individual, there is already a problem the caller has not been able to handle, so there is already some sort of incident.

HIPAA: That cleared up a lot for me. What we need now is a law that actually does make patient information as private as the patient wishes it to be. If FaceBook can have various privacy settings, then so could an electronic medical information system. This is just a question of people wanting it to happen.

Right now, corporations are making decisions about our privacy for us. I heard on NPR recently that Americans have allowed businesses to have there data. Allowed? My perspective is that in many cases the companies take the information without our permission. If you own a cell phone, you have no way to opt out of having a list of your calls saved by the company, for example.

Learning From Diabetes: Interesting. There are other cutoffs that have been altered. BMI levels used to determine "overweight" and "obese" were lowered, putting people into the obese category who look to the casual observer to be overweight. The number that separates normal from high blood pressure was lowered. With the latter two, it is my opinion the changes were made so that medications and procedures can be used for people who previously did not qualify. This is very beneficial to pharmaceutical companies. If the criteria for diabetes is lowered, more prescriptions are written. The numbers chosen as cutoff points are big business, and to stay clear of a financial motivation there needs to be separation of the medical community from Big Pharma, but there is not.

Je suis said...

I have a few problems with Dr. Smith's article that I will attempt to explain in brief here. I will probably sound like a broken record since some of it I have mentioned before, but it bears repeating.

1) His work requires him to assess dangerousness, inability to care for self, or inability to make good decisions regarding self care.
I have mentioned it before, but here it is again - it is a matter of legal record that psychiatrists cannot predict dangerousness. The APA testified to this. Yet, he is committing people due to his ability to predict dangerousness?
How about the inability to make good decisions? like seeing a psychiatrist, perhaps? If you don't see one regularly, is it a
bad decision? What about smoking?
Isn't that now regarded as a bad
health care decision? Are we going to commit smokers now? How about the obese? I think you get the point.

2) "Well, yes, I can do that, and no, you’re not going anywhere, and yes, I can stop you."


"I have seen patients go from being in my face and hostile and threatening to kill me on the spot to blubbering wrecks when they find that I am done talking and ready to act to protect myself (and them) from their rage."

These two quotes from his article sound a lot like ego; a kind of "look what I can do to you if you don't bow down to me" kind of attitude, instead of someone trying to be helpful.

3) "I have committed some of them," & "gone home and rested well that night, knowing that they would get the assessment and treament they needed in a safe, secure place."

"I have let some folks go, only to find out that the next day or the next week or the next year they overdosed or shot themselves in the head or hanged themselves. Their choice, not mine. Doesn’t matter. It kills a little part of me anyway, every time it happens."

Two things here: #1, the treatment they receive is almost non-existent in these facilities, and they are definitely not "safe". After all, people are sent there for being dangerous, right? So the dangerous (to others)
individuals are being locked in with the dangerous (to self) and the "inability to care for self" or "inability to make good decisions" individuals - how safe is it to trap poorly functioning people in with dangerous people?
Is this some kind of joke? How sadistic is it going to get?

The second thing: if he commits someone, he goes home and rests
well, but if he doesn't commit, and they do suicide, it "kills a little part" of him? So, there's no incentive to commit here, then?
Right? it's completely impartial, with only the patient's best interests front and foremost? Somehow, I doubt that very much.
Even though it's "their choice", not his, it seems that he has more than a little invested in that choice. Like taking that choice away so that he can sleep better.

Anonymous said...

Dear Shrink Rap hosts and readers,

Thanks so much for linking to my blog recently and continuing the conversation around treatment, involuntary commitment, trauma and other associated issues. I realize that these are topics you have visited often before, and I appreciate being able to add to the dialogue.

While I am not going to respond to each individual point in your discussion, I would like to add some general comments if I may.

First, there is always the risk of trauma when someone divulges thoughts or urges or plans for self destructive behaviors that pose an imminent danger. In those cases , it is clear that action must be taken, and quickly, to prevent harm to the person or persons involved. That action is sometimes involuntary commitment to a secure facility. No one would argue that this system is perfect, but it is one avenue to prevent life threatening injury in a true emergency situation.

That is very different, in my opinion, from the therapeutic situation where rapport has already been established and an atmosphere of trust exists. A patient who has dark or distressing thoughts is sure that they can trust those thoughts to their psychiatrist, who will then help them work through this very difficult time without fear of being whisked away in handcuffs in the back of a squad car. The key here is whether imminent danger exists and action is mandated.

The decision to commit someone against their will is never made lightly. It is not always obvious, and it is never easy. Sometimes, the decision to take such definitive action is based on presentation, previous history, years of experience, and the clinician's comfort with the alternatives.

Rock solid prediction of dangerousness or self harm is not one of the psychiatrist's jobs, even in an emergency room setting. However, assessment of potential dangerousness and potential self harm or harm to others most certainly is.

This is such an important part of every mental health evaluation in the emergency rooms in our system that there are two entire sections of the electronic medical record devoted specifically to prompting the clinician to ask a set of questions that point to well known risk factors for suicide or harm to others.

I realize full well that some of your readers have had bad experiences with treatment in various settings. There are bad doctors. There are bad hospitals. There are shoddy programs that offer limited help. There are times that law enforcement is too heavy handed or that overzealous doctors overmedicate.

I am not trying to explain these away. I applaud your readers for being passionately concerned about the state of our mental health system today. I would implore them, as I do all of my patients and families who have specific concerns about quality and availability of services, to voice these concerns where they can best be heard.

Advocacy groups, legislatures and executives at the local, state and federal levels make the laws that govern us all. Professional groups come up with the criteria for diagnosing illness. Federal agencies mandate documentation, reporting and coding of services.

Let you voice be heard in any and all of those arenas. The system will change slowly, as all systems do, but it can change.

Greg Smith MD

Je suis said...

While I appreciate Dr. Smith's response, it just serves to illuminate some of the problems with psychiatry as it currently stands. First, there is the issue of the risk of trauma when thoughts (and please note that Dr. Smith clearly states that thoughts of self-destructive behavior are sometimes enough reason for commitment, contrary to Dinah's post earlier that no one is committed for thoughts) or urges or plans for self-destructive behavior is divulged. This ignores the very real risks to the patient when forced into hospitalization against their will. After all, there are many who have stated that it did not help, and instead caused more trauma, at least psychologically: the trauma of being treated exactly like a criminal, including being handcuffed and "whisked away" in a police car; despite having committed no crime. Then the trauma of commitment; so much like jail time with it's loss of freedom. That is, of course, if you survive to reach the facility; the police are there to force you however they must, and will use deadly force if necessary. There are plenty of incidents of the police either shooting a mentally ill person or, more commonly, using a taser for pain compliance. The problem is, you might survive the torture - and pain compliance is torture - but then again, you might not; people have died as the result of being tasered. This is real, physical trauma, sometimes ending in death. But the purpose is to prevent that death, isn't it? How to explain this seeming hypocrisy? This acceptance of trauma inflicted upon a person in order to prevent that person inflicting trauma upon themselves? It would appear that it's not OK for you to harm yourself, but it is OK for you to be harmed by the very people who decry your harm; the same people who initiate force that could end in your death - this isn't about helping someone, it's about control, and mitigating liability.

Second, "assessment of potential dangerousness" vs "prediction of dangerousness" is wordplay, nothing more. Let me help: everyone, bar none, is 'potentially' dangerous. We all have the potential. What you are assessing is the probability, not the potential. And assessing probability is, basically, predicting. Predicting dangerousness. Something that, again, has been made a matter of court record as being something that a psychiatrist can't do reliably.

Third, the "help". There is actually very little help to be had. Drugs, therapy, maybe ECT. If those don't help - and the first two did not for me, the third I will not risk - then that's it. Not much more to it. So, if those have been tried, or are not wanted, why should anyone wanting to end their suffering be forced to endure it - especially again? It is unwanted, or ineffective, yet you will be forced to go through the same nightmare repeatedly? how does this help? It does not, but it certainly harms.

In the end, psychiatry may help some, but it seems to harm just as many - that seems a poor efficacy rate for a medical business, particularly one that is forcing people to accept their services against their will.

Nathan said...

I agree Je suis with the wordplay argument. I don't know with what skill, technique, experience psychiatrists believe they are better assessing dangerousness than anyone else. The APA has clearly stated that it can't predict dangerousness, something they should have done, because it is a move to rightfully keep them out of the business of being drafted by state powers to be put in position to do an impossible task that comes with a lot of liability.

If Greg does not like the process people go through as part of being involuntarily committed, than he should abstain from involuntarily committing. Legislators, advocates, policymakers, and federal agencies defer to "expertise" and standard procedure of psychiatrists, not to people who have experienced systemic trauma and are in distress. If you believe things should be different, change your procedure and work with your professional organizations and employers to change their stance in regards to making involuntary commitment "better." That would be a more likely successful strategy to make changes, if you really believe in the value of involuntary commitment. If you are not willing to change your own short-sighted practice of keeping people alive for a few days longer by increasing their exposure to distress and increasing mistrust of those who are positioned to help, then I don't know who or what you are protecting by involuntarily committing, but it certainly isn't patients.

Anonymous said...

Here is what every medical professional who has the capacity to commit someone should experience BEFORE they are allowed to commit someone involuntarily:

1) Sitting quietly at home, working or reading, in their jammies. Knock at the door. Police burst in, take them down, face to the floor, arms wrenched behind their back. Handcuffs go on, and they are walked to the police car a block away in front of all the neighbors.

2) 24+ hours in the psych ER, with no food and very little water, with disturbed patients crying and screaming the entire time. No doctor, nurse, or other staff members appears to know what will happen next, or at least they won't share it with you. Won't even tell you why you are there. No phone calls or reading material allowed.

3) transport to a psych hospital via ambulance, with arms, legs, and chest strapped down to a stretcher, even though you've been as docile as a drugged sheep this entire time.

4) a several hours long admission process to the psych hospital administered by someone who speaks almost no English; still no food or water, still no idea why you are here.

5) your first meeting with a doctor consists entirely of him telling you of the six (!) meds he intends to put you on: an atypical antipsychotic, something to counteract a side effect of that, something for pain, something for sleep (an antidepressant), a multivitamin, and a potassium pill. You refuse them; he reminds you that he can and will recommend forced medication if it comes to that.

6) More than 48 hours since you were face down on your living room floor in cuffs, a social worker visits with you and finally tells you that your estranged (and angry) partner has filled out a commitment form for you alleging that you are a danger to yourself. His (or her) word is the entire basis of your commitment. At this time you are told that in another 48 hours you will go before a judge who will determine whether or not the state can hold you for SIX MONTHS.

7) During the entirety of your stay the only therapy you receive consists of a daily 5 minute visit with your doctor and a handful of group sessions that turn into shouting matches between other patients.

8) With a few hours to go before your hearing a nurse thinks to ask you if you want a lawyer or if the public defender would be fine. When you meet the public defender it's clear she has never even looked at your records. During the hearing your doctor testifies against you and lies.

9) After the judge decides in your favor and determines the hospital cannot hold you, the hospital discharges you. To the street in front of their door. With no money or phone. In the red flannel jammies you had on when you came in.

I didn't deserve any of this, I don't care how sick I was. It did nothing for me except teach me to stay away from doctors and lie to everyone about my mental condition. I have absolutely no doubt that everyone involved with this sleeps well at night. Except for me. The nightmares never stop.

Anonymous said...

To the previous anonymous,

Hmm and psychiatry doesn't understand why people are are so angry? Maybe the next time I read another post that alleges that people who speak out against psychiatry are crazy scientologists, I will provide a link to your post.

What was done to you would be called torture in old style Soviet Russia when dissidents were drugged against their will. But in the good old USA, business as usual.

Sorry for my rant as I wanted thank you for sharing your experiences. I can't imagine how terrified you felt and my heart aches aches for what you went through.


PS - Your lucky the judge let you go. Many people are not so fortunate in your situation.