Monday, July 15, 2013

Guest blogger Dr. Jesse Hellman and the Question of Whether Ralph Rackstraw was Certifiable

O wad some Power the giftie gie us
To see oursels as ithers see us!

These lines are from Scottish poet Robert Burns. He could well have added that we might have the gift to see better what others mean by their acts and words. Two sides of the same coin, perhaps, but very important in trying to understand the issues of involuntary hospitalization that are often discussed here. Yesterday Dinah and her husband joined me and my wife to see HMS Pinafore, and at intermission I commented to Dinah that in today’s culture one of those sisters, cousins or aunts might have called 911 when Ralph Rackstraw talked of suicide: he had the means, he expressed intent, and he believed Josephine did not love him. How differently the play would have gone if he had been quickly certified for observation in the local hospital (see Hogarth’s portrait of Bedlam in “A Rake’s Progress”)!

Recently I have heard of numbers of people (some SR regulars) who were hospitalized without what appears to have been good reason, and then were treated quite harshly and callously on the ward: forced medication and humiliation, which took quite a toll on them. I have no reason to doubt their experiences, but do not understand what exactly transpired.

It led me to ponder more on how we come across to others, and in telling our version of events what is it we stress or do not, what we understand of the other person’s perspective, what they would react to, or not. Have you ever had the experience of meeting someone, engaging in a spirited conversation, and then later hearing from a mutual friend the other person’s version of what went on (if you say “no” think back to dates you had in college)?

This failure in empathy and understanding can occur on both sides, but I suspect it is almost always there in some form. Each person sees only a part of the full picture, or reports it in a manner different from how the other would tell it.

So when someone writes that he did mention to the doctor in the ER that he was having suicidal thoughts but expressed no plan, and was then certified, I wonder what the doctor or others had heard and observed. I wonder what unknown pressures the ER personnel are under, what might have happened recently, what went on in their own lives. At times when people write that they had turned up in an ER I wonder why, and what concerns and fears they had created in others, of which they were unaware.

What experiences have you had in which later you realized that either you or the other person heard or experienced something quite different from what was consciously intended? I would hope in response to this
post we could stay with the question of perception of ourselves and others, as opposed to the many other directions in which the comments might go.


Joel Hassman, MD said...

Good luck with this thread, the characterological factors that in my opinion are often behind the less than stellar outcomes from involuntary admissions will never be dealt with honestly and directly.

Plus, I know the addiction component only confounds logrithmicly more often than not.

are ya strapped in for the ride?!

Anonymous said...

Dr. Hassman: Matthew 7:3.

'Nuf said.

Anonymous said...

Interesting post. Not surprisingly, I didn't come away from the posts about involuntary hospitalization with the same view point as Dr. Hellman. I didn't remember reading that "numbers of people were hospitalized without what appears to be good reason." I only remember a couple saying they didn't meet criteria. What I remember is that a number of posts dealt with how hospitalization had harmed rather than helped. So, I think the differences in how we remember the posts are strikingly different.

It is interesting that we came away from reading the same posts with vastly different perspectives, perhaps our own experiences are influencing how we each read and interpreted the posts? I will have to go back and re-read to see if there were numbers of people arguing that they were hospitalized not having met criteria, because I just don't remember very many saying that. I remember one, maybe two, people arguing that they did not meet criteria, but mostly I remember a number of people arguing that it had not been helpful and talking about the pain it had caused. But, maybe that is my own personal experiences coloring what I read and remember.


Anonymous said...

"What experiences have you had in which later you realized that either you or the other person heard or experienced something quite different from what was consciously intended?"

I always have a difficult time, and debate, whether or not to tell a doctor I am on psychiatric medications because I worry about being judged, and worry it will negatively affect how I'm going to be treated. I remember the first time I saw my PCP, I was (reluctantly) honest with him about the psychiatric medications I take. The first thing out of his mouth was, "I can't refill the Vyvanse." I was not there for a refill on anything, and I immediately snapped at him and said, "I didn't ask you for a refill. The psychiatrist put me on these medications, and I don't even want to be on these stupid medications." Then, I took a deep breath, and calmed down and told him how difficult it was to actually come in and admit to him that I see a psychiatrist and take psych meds. I told him it was embarrassing, but I had thought he probably wanted to know the medications I take. He immediately softened and was very kind.

I realize we both started out by reacting out of fear. He was afraid I was there to try and get more stimulants, and I was afraid of not being taken seriously because of the medications I take, and/or presumed to be a drug seeker.

Once we both realized where the other was coming from, it actually turned out to be a really good working relationship. While it sucked to automatically be assumed to be coming there for a refill when I wasn't, I also realize he is human and was trying to do the right thing. I forgave him, and we get along quite well.


Nathan said...


I am impressed with your ability to lead the conversation with your physician about your feelings and needs in regards to your experience of seeing a psychiatrist and taking psychiatric medications.

I think it is often underplayed here and elsewhere that health professionals (mental or otherwise) do respond to people tagged with psychiatric labels are take psychiatric medication with a lot of fear, assumptions, and disregard. It is great that people like Pseudo-Kristen are able to navigate relationships with these professionals, but it really is systematically oppressive that it is on patients to have to always risk mistreatment through expressing their vulnerabilities and have to placate the fears of the unjustified posture of the professionals treating them, as any expression of fear, anger, somatic complaint, or procedural questioning from someone with a psychiatric label is seen as symptomatic and self-confirming of false assumptions.

I know I have to do a lot of forgiving of health professionals for their erroneous assumptions, and I have to do this without them asking for forgiveness, and I also know that I am not often given that consideration when I experience a wave of defensiveness when my motivations are questioned.

In more direct response to the post at hand, I get that health professionals have their own issues and lives, that hospital staff is overworked and tired and often inexperienced, and that they have seen some pretty bad stuff, and that these all color their experience. I think the important part of being a professional is being able to with some rationality and objectivity examine states of exhaustion, anxiety, memories of bad experiences, etc. and recognize that they come from them and not from a patient in front of you. I think that is the most important thing a person can with a degree that gives them a lot of coercive power to learn and the primary thing they are paid for. Seperating their own crap from that of the person you are treating and owning the consequences when they don't. Patients, like Psuedo-Kristen, shouldn't be the ones having to do this all the time, as they are not the ones getting paid.

Susan Inman said...

We don’t often hear from people like the many I know who benefitted from the involuntary treatment that their illnesses prevented them from understanding they needed. Here is a link to the archive of the Huffington Post Canada articles by Erin Hawkes who makes it very clear that she would not be well or even alive without involuntary treatment:

jesse said...

Thanks, P-K, for your thoughtful example. It speaks very well to the two sides of the issue.

In regard to your earlier question, I was not basing my thinking on only the recent SR posts, but in response to these questions had discussed it with others and came across further examples of people who had quite different versions of what happened in the ER from what the admitting doctor had seen. This led me to think more about the complexity of this issue.

Anonymous said...


I am curious, if one of your colleagues told you about the "patient from h-ll", would you be interested in hearing the patient's side? By the way, I am not asking this question to play gotcha but perhaps to point out that as P-K said, our experiences color the situation and whether we think there is another to the story.

For example, on an email list I belong to, someone criticized a special ed teacher in a news article for being abusive towards a student with autism. While I certainly agreed the criticism was justified, I wondered what the teacher's version of the story was. This happened because having worked in special ed with that population group, I had experienced the other side of the situation which had included getting attacked.


jesse said...

@AA, yes, certainly I would. Very good point.

Dinah said...

I think the parallels between teaching and mental health care are enormous. There is a whole set of rules, most of which made perfect sense when instituted (document X in the record, teach to these tests), but don't always translate well to the situation at hand. There are 2 sides to the story (sometimes, not always). For one kid, "I was fresh and the teacher put me out in the hall", for another kid, "all I said was X and the bitch threw me out of the class." And everyone comes to the table with their own issues...a child spoken harshly to because the teacher learned last night that her husband had been cheating on her for years, a nurse who keeps a patient in seclusion for a little too long because she's lost in thought over her parent's divorce.

Some people just don't belong in helping professions, but even the best of professionals are still just people with their own issues, and sometimes great teachers and great students don't 'click' or patients just don't have chemistry with a mental health professional. It doesn't make anyone wrong.

Anonymous said...

Thanks Jesse, I am glad to hear it.


Nathan said...

Dinah and Jesse,

The big difference between folks in helping professions and folks they purport to help is that as paid professionals, it is actually people's jobs to apply some objectivity and rationality to their interactions with people and separate their issues from what their patients experience. While understandable, it is not ultimately ok to treat someone poorly or wrongly because you had a fight with a spouse or are preoccupied with a family issue, or if you have had a long shift in the ward, or if just last week a patient got aggressive and you got scared, or if you are inexperienced. If it happens, it is the provider's responsibility and they have to own that and hopefully be willing to deal with it with fairly and openly (our legal system often prevents this). They are the one with the degree, license, coercive power, and fee/paycheck for services rendered, not patients. I think it is setting up a false equivalency and banality to say something like "sometimes patients and doctors have two different takes on a situation colored by their own experience, and both parties can learn about what happened through examining their two sides." If one party has power to commit or diagnose, they should be more responsible in separating their feelings from their actions.

Psuedo-Kristin notes what many who take or have taken psychiatric medications or have psychiatric diagnoses experience when dealing iwth health professionals. The very real presumptuous and unjustified fear and belittling of our needs and experiences when we disclose our histories. Again, why is it that patients have to work hard to be judicious and careful and diplomatic when explaining this to providers. We're not getting paid to do that work. Why must we forgive them without them asking for forgiveness when they are presumptuous, though we are asked to understand that of course doctors are people too who have their own issues? Doctors have to own their decisions, even if and especially if factors not pressing to their treatment decision affected their decision. If that is expected of patients' experience of their physicians, than it should moreso apply the other way.

I know in my own experience of trying to communicate what had colored by experience of a mental health professional in a more emotionally resonant way, which was requested of me by the mental health professional, was used to further diagnose and I believe discredit me. It was an incredibly disempowering and humiliating experience to be asked to engage in a discussion of reconciling different viewpoints to only have the party with the diagnostic and coercive power to define the situation to use that power to against me in that "official" record, and later admitted to doing so.

So yes, let's try to understand what others perceptions of us are, but recognize that any preconceived perceptions should be questioned and challenged, and no one should be doing this more than mental health professionals.

Just me said...

We are all human, understood, but let's go with the nurse analogy. Make the nurse an anesthethetist preoccupied with her husband running around behind her back. Turn the seclusion a little too long into an overdose of knock out drug during a long operation. Just because it's understandable doesn't make it okay.
In my experience, medical personnel who know me do not judge me or view my things such as anxiety over an MRI as a manifestation of mental illness. They treat me like a person, not a waking diagnosis. Some, not the majority of medical personnel who do not know me but who do know my psych diagnosis seem blind to anything but and any presenting problem becomes a manifestation of mental illness as soon as they open my chart. So in these cases, it is not about what behavior I am presenting with. It is about a stereotype of people who carry certain diagnoses. It isn't ant different than what Dinah just posted about assuming all obese lie around all day stuffing their faces with junk. As a person with a diagnosis who takes medication I am not allowed the luxury of a bad day. Other people get to have bad days. If I have the same bad day , it must be time to call the hospital. I don't get to be anxious. I only get to agitated. I don't get to be joyful. Watch out, I might be getting manic! I don't get to be sad when my dog dies or even if my mother dies. I'm showing signs of a mood shift, might need to up my dose.
To tie in two supposedly unrelated posts, I don't agree that obese people are the only ones left getting blamed for their difficulties. We have a very long way to go in mental health before those with mental illness are viewed as fully human.

Just me said...

Walking not waking

Sarebear said...

I was tempted to post something, using my gp or my therapist as an example, but then I get all anxious about people criticizing my doctors so I just can't.

Still wanting to participate, just having a hard time sometimes. Going back and forth between saying too much, or saying nothing . . .

What's the point of this? Probably me trying to still participate here but expressing frustration with my anxieties that are messing with it, or my often rambling about whatever . . . shutting up now, but I'm still here.

Sunny CA said...

Hi, Sarebear!