Monday, September 02, 2013

Deeds, not Diagnosis.

Here on Shrink Rap, we've talked at length about the implications of having a psychiatric diagnosis on one's future occupational endeavors.  For example:

We've talked about whether you can have bipolar disorder and be a doctor.
We've talked about the fact that a psychiatric diagnosis prevents you from being a pilot.
We've talk about psychiatric disorders and being in a powerful political office.
We've noted that the New York Times recently ran an article on psychiatric diagnoses and how it affects one's ability to be admitted to the Bar Association.
We've discussed mental illness and gun legislation

 What the DSM does for us is it gives us a list of symptoms that go with every diagnostic category.  It means that if a patient presents at a given time with a specific set of symptoms, and they are examined and a history is taken, that different psychiatrists at that point in time, with the same data, will come up with the same diagnosis.  It's actually good for that, and we call this inter-rater reliability.  

What the DSM doesn't do is tell us which patients with a given disorder will get better with medicines, will get better without medicines, will respond well to therapy, will do better without medicines, or will be hopelessly sick and disabled no matter what is done.  Schizophrenia is often a poor prognosis illness to have, and nothing about diagnostic criteria tells us who with schizophrenia will become a law professor, like Elyn Saks, and who will end up living in a cardboard box under a bridge.  

Given this fact, we need to stop using psychiatric diagnoses for anything to do with occupations or gun ownership or drivers' licenses, or much of anything else aside from the treatment of psychiatric disorders.  It's silly anyway: Why should you be prevented from being an attorney because you have a history of a mood disorder, but it's fine for you to be a school bus driver with dozens of children depending on your mental stability?  

We need to judge people's competence based on their deeds.  If you run naked through the hospital, you can't be a surgeon there (not this week, anyway).  If you're so depressed you can't get out of bed and you're always late to work, perhaps you shouldn't be President of the United States, because I hear it entails being at a lot of meetings and press conferences.  If you're behavior when ill leads you to do illegal or dangerous things, then you should be barred from doing things that one needs to be a safe and law abiding citizen to do.  But it's the behavior, or the expressed potential behavior that counts.   So if you've quietly been depressed, gone to tell this to a psychiatrist who prescribed you a medication that took that depression away, and a pill and some therapy keep you well, then why shouldn't you be running the country or driving those kids to school?  Oh, there's risk, you could get depressed again.  But you could also have a heart attack or get cancer or epilepsy or Alzheimer's Disease.

When I'm on a plane, I want a pilot who does a great job of flying a plane.  Perhaps there are some objective measures of what we want to see in a pilot -- things like reaction speed which could be impaired by depression or by medications.  Instead of stopping someone from flying because his depressive symptoms are adequately addressed with an antidepressant, perhaps we should be checking his reaction times on a simulator.  If a pilot does a great job of flying, then I don't care that he's on an antidepressant, and I don't care if he's thinking about his grocery list, or anything else that I have no control over.  But  I do care that he flies well, that he's not impaired, and since history may repeat itself, then I care about his past behaviors: if he's had close calls when flying for any reason, or a history of a suicide attempt, then I'd like another pilot, please.

And I personally don't think anyone should own guns, but since no one cares that I think that (yes, yes, 2nd amendment...), well then what say we prohibit the following people from owning guns, at least for a period of time: anyone with a history of assaultive behavior, and anyone who has had a suicide attempt serious enough to require medical attention.  Both imply that the person has a level of impulsivity where a gun could be a problem.  And, yes, I think that someone who gets in a bar fight and throws some punches shouldn't have a gun, at least for a given period of time -- say long enough to age into some brain maturity or get some treatment for their alcohol problem. 

 I don't care what the diagnosis is: no diagnosis precludes any type of employment, and no lack of diagnosis is any guarantee of safety.  What matters is behavior, and that's what people should be judged on.  Oh, you're going to say I think this means it's okay if the pilot tells his co-pilot he's thinking of crashing the plane: and I'm going to say No!  The act of telling another that you have violent criminal intentions is a behavior, that pilot should not be permitted to fly.  Silent thoughts which one never intends to act on are one thing (we all have weird thoughts from time to time), expressing such thoughts can be a cry for help, or it can indicate poor judgement, or it can be an expression of a symptom of serious mental illness, but once expressed, it's a different animal than a quiet fantasy.  

We need to change the questions.  'Do you have a diagnosis of X,Y, or Z' is not relevant.  Have you ever been convicted of a crime beside a minor traffic violation?  Have you ever filed for bankruptcy (I don't want you running my accounting department, thank you, anyway)?  Have you ever been treated in a psychiatric facility for violent behavior or a suicide attempt?  Have you ever been committed to a psychiatric facility involuntarily for dangerous to self or others  ("committed" implies that you were not just observed for 72 hours, but that a hearing was held where you were determined to be dangerous by a judge).   And for many of these things, there should be a period after which it's no longer an issue.  A single suicide attempt at age 15 following a break up with a boyfriend, followed by years of mental stability as an adult should not haunt one forever.  Maybe 7 to 10 years without troublesome behavior is enough.    But a diagnosis of Bipolar disorder?  Now what does that mean?

Okay, rant.  And please tell Clink that "twerk your giblets" is not something that normal people say.


Anonymous said...

Do you ever tell patients that they are not allowed to drive, or should avoid work?
I ask as during my last stint in hospital I was stupid enough to try and drive myself there and while being admitted the nurse tore me a new one when she realised I'd driven there.
Upon reflection doing so was a pretty stupid idea and I've made a mental rule not to drive when I'm feeling unwell, but at the time I thought I was fine.
I know neurologists and cardiologists can ban someone from driving and have their licence revoked until a person is well enough and medical certificate of competence is written.
Do you ever tell people to stop doing certain activities while unwell? Do you ever go so far as getting a licence revoked?

Unknown said...

Great post, Dinah!

Dinah said...

I try not to tear anyone a new one for any reason, they already have an old one.

I don't tell people not to drive, unless they look impaired in my office, and they don't listen to me anyway. Once or twice, I've offered to make someone coffee if they looked very sleepy.

Patients have given me forms to fill out from the MVA saying they can drive. Here's where you need a test/simulator. I never see my patients drive, I have no training in driver (or gun safety) assessment, how could I know something like this???

I believe that the law in our state is that you must be seizure-free for 90 days to drive. You can lie to your neurologist if you're not seizing in front of him, or you could not realize you had a seizure you should be reporting, but at least there is some vaguely objective measure there.

I've suggested that people who have multiple car accidents in a short period of time may not want to drive because it doesn't seem safe.

I do tell people in the midst of a psychosis or who are manic to stay home from work and I give them a note. I like my patients to avoid the issue of running naked around the hospital where one works. While someone could look it up, my stationery does not say I'm a psychiatrist. If you want to keep your job (diagnosis irrelevant), it's better to keep certain deeds from happening in the workplace.

Anonymous said...

I have a lot to say on this because I am bipolar so I have lived through what you are discussing. (awesome post) but I don't want to take up all your comment space so if could just look at my post about this on my blog I would appreciate it.
Anyhow, I love your blog and I have never used any phrase that uses the word twerking and giblets in the same paragraph.

Nathan said...

Dinah, I appreciate this blog. Diagnosis should not have wider implications beyond treatment. When they do, as they do now, it creates barriers to care and drafts mental health professionals in a system of oppressing distressed people more than they already are.

I will also push back on your "deeds" philosophy. Who gets to decide how long after a "deed" or "event" until someone can resume typical living? Must a financial planner who has filed for bankruptcy never be a financial planner again (or wait 7 years?) What about a couples therapist (or nay therapist) who gets divorced, or never was married, etc? Should they no longer practice? Who gets to decide their fitness for practice?

My goal is to get set determinants out of a lot of these decisions. You are free to advise your patients as you wish, but you shouldn't rule them out from the get go based on behavior or diagnosis.

Dinah said...

The point was to leave the psychiatrist to treat people and divorce them from this business of being society's watchdog.

These can be legal issues, like the seizure-driving law. There are consequences to filing for bankruptcy, I imagine the financial planners association determines it and I imagine they don't like it. Or maybe they don't monitor it and don't care.

Someone who is psychotic at work may well get fired. If you're doing things that are disruptive to the workplace, or can't do your job, they typically fire you without involving your psychiatrist.

I'm simply saying that because someone was diagnosed with X Disorder (perhaps in an outpatient setting), or was hospitalized once years ago for an initial presentation of but has remained well since, that they should not be excluded from any profession.

If someone requires ongoing care to remain well, then it might be reasonable to have a psychiatrist confirm that they are coming to appointments and doing well and state how long they have been doing well before allowing to be President with access to that magic button.

But if no one in your workplace knows that you are treated for panic attacks, if they are well controlled by medications that do not impair you, alter your behavior, slow your reaction times, decrease your judgement and neither the problem nor the treatment are problems, then what's a diagnosis got to do with the price of beans? It could have been wrong, anyway.

Behavior is different. It's not something confined to a doctor's office.

Je Suis said...

A few things I have a problem with (part 1):

"if he's had close calls when flying for any reason, or a history of a suicide attempt, then I'd like another pilot, please."

Essentially, you have stigmatized this unknown pilot by equating an attempt to end his or her own life with the desire to end the lives of others. So much for psychiatry and all it's 'help' - you, a psychiatrist, believe that a suicidal person is also homicidal, and that a history of suicide means that that person can never be trusted again; basically, that he/she will never actually recover - so much so that you refuse to allow them to practice their profession, at least when you are directly affected. I guess actions do speak louder than words, and this says a lot about the reality of psychiatry, not to mention the foundations of stigmatization. So hey, thanks for all the 'help'; help that you clearly don't believe in. After all, if there is a history, then it follows that the individual in question received the "help" that psychiatry offers, doesn't it?

Then there's this: "And I personally don't think anyone should own guns" - o.k., fair enough; I personally believe that no one should be forced against their will into the mental health
system, but there you have it. You think guns are bad, I think psychiatry is, well, at best, useless. Opinions differ, it seems.

Je Suis said...

(Part 2)

Let's not forget this gem: "I think that someone who gets in a bar fight and throws some punches shouldn't have a gun, at least for a given period of time" - why? They didn't use a gun, after all. I was in a bar once (well, more than once, but this is about a particular incident) where I was
grabbed by two guys who said they were going to "take care of me" (no, I don't know what they meant, exactly, and I didn't bother to inquire). Guess what happened next?
Let's just say, some punches were thrown, and I got out intact. So, by your reasoning, I should lose my gun rights for defending myself?
Because I need to age into brain maturity? What, exactly, in you infinite maturity, would you have had me do instead? Try reasoning with two aggressive drunks that already have their hands on me? Really?

On the surface, it appears that you are advocating for individuals with psychiatric histories, but when you break it down, your exceptions add up to more of the same stigma, limitations, and general distrust that psychiatric patients face already. You're adding fuel to that fire with ill-considered reasoning like " Have you ever filed for bankruptcy (I don't want you running my accounting department)" - I mean really, there are plenty of intelligent, capable people out there who have been forced to file bankruptcy through no fault of their own; mainly due to job loss (I know one person who hasn't been able to find a job for over 2 years and the unemployment ran out long ago) or other unforeseen crisis, such as a medical issue (and we all know that medical care is exorbitant in its costs, just look at the charge for one office visit - but I'm sure you are aware of that, right?) Remember, our wonderful government estimates that a full 53% of working age Americans are either unemployed or underemployed (part time w/o benefits). This doesn't make them incapable, it just means that they no longer have the resources to avoid bankruptcy. Why do you assume that they would then be unable to properly perform thee accounting functions of a business?
Is the business also out of work or otherwise lacking the necessary resources? If not, then it's an apples to oranges comparison, kind of like when a suicidal person is considered to be homicidal. Once again a stigma rears its ugly head.

"Have you ever been treated in a psychiatric facility for violent behavior or a suicide attempt?"
Do you really want to ask this question? And hang so much of their future on the answer? If so, then I submit that psychiatry has nothing at all to offer to anyone who has attempted suicide, since so much becomes attached (with your approval, apparently) to the
answer. If it's yes, then the stigma, limitations, loss of employment opportunities, just to name a few repercussions, all go into effect. Oh, to be generous, maybe only for 7 to 10 years? That's hardly helpful, and points to the fact that psychiatry cannot help you, or even if it can, it's gonna be a long, long time (yes, an Elton John reference) before you can be trusted again, if at all.

In all this, the only position that psychiatry tends to take is that there's still hope. Somewhere. Somehow. Somewhen. You'll just have to wait. And wait. Of course we can help you, just please, don't fly my plane. Because I don't really believe that we can help you, I just told you that. You know, hope and all that. Cause it gets better. Not really. But it does. Maybe. I don't know, but to be on the safe side, stay away from any job where you might hurt someone. Because you were suicidal, and therefore, by default, homicidal. That's not stigma, it's a fact. But there's hope. Really. Somewhere. Just trust me, even though I don't trust you.

This, then, is the real face of psychiatry. And it's not pretty.

Dinah said...

Je suis,
I do believe that we will never agree on some of these issues.

I will contend that if you were convicted of an assault charge for your bar fight, then you should not own a gun. I think this is civil rights issue, I am not saying that the bartender or the guy on the next stool should be reporting you to the FBI database, and hopefully, if you were arrested and charged, the fact that it was self-defense came up at the hearing, perhaps you were found not guilty, and you can go home to your guns.

As it has been until very recently, you can't be a pilot if you've had a psychiatric disorder. That simple. Even if the medicines totally cure you, even if you've never been suicidal. I don't want a pilot who has had a suicide attempt serious enough to require medical intervention. I'm fine with some time table there, (teenagers do dumb things).

The world apart from psychiatry has natural repercussions. If you declare bankruptcy, there are things you can't do. I have a blog and an opinion, I don't worry too much that anyone is actually listening.

If you want to fly with the pilot who's had a serious suicide attempt, that's fine with me, but I don't think the rest of the world is so keen on that. Are you waiting until one week or two weeks after his discharge from the ICU?

Oh, and have you ever been treated for being violent is a far cry better than the current standards which keep people out of the legal profession simply because a psychiatric diagnosis is attached. I did assume that if the answer is yes, there's a line to explain, and that "15 years ago I swallowed some pills and had treatment, but have been doing well since and was discharged from treatment 12 years ago" might be something that would allow one to move on . The numbers are invented, I don't mean them to be literal. It would not trouble me in the least if my lawyer had bipolar disorder and was either stable, or took a leave during episodes of illness. Now I just need a lawyer.

Anonymous said...

"Twerk your giblets" is brilliant!

jesse said...

Dinah, this is one of your best posts ever. You are honestly recognizing the limits of our profession, of current diagnostic methodology, and of the varying skills of those who make diagnoses and authorize admissions, when you say that a diagnosis per se should not be disqualifying for so much as it is today. In general, though, and this is true for the various Bar associations, a diagnosis flags an individual for review, not automatic denial. The professions have a legitimate interest in attempting to make sure that a person who has a license from the state to treat, represents, administers to, etc the public, as a lawyer, doctor, nurse, and so on meet certain standards. The same is true here in Maryland for driving a car.

I can't recall exactly who said "if we were judged by our thoughts no man would escape hanging." So while ones thoughts and desires are provide deserved material for confession and psychoanalysis they are not how we are judged in society. Our words and actions are another matter entirely.

Anonymous said...

Would you let a friend who had once made a serious suicide attempt drive you to a movie?

Anonymous said...

The saddest thing of all is that these types of rules prevent people who need treatment from getting it and/or from being honest with their psychiatrist about symptoms for fear of getting a particular diagnosis. People don't want to put their jobs at risk just to seek treatment, so this increases the likelihood that people don't get help until it's a disaster. This is not the right thing to do.

I work in the healthcare field and doctors and nurses are discouraged from seeking psychiatric treatment because they know if they get diagnosed with particular diagnoses they will have to say (or lie) when they renew their licenses. I would imagine that what happens if they say "yes" to the particular diagnoses asked about is that they then have to turn over their medical records, and so forth. We punish the ones who get seek treatment. That makes no sense.

I think it absolutely should be about the behavior. If I get great reviews work, which I do, then my seeing a psychiatrist shouldn't matter. My license is safe if my psychiatrist calls my illness agitated depression or depression + anxiety, but I'm screwed if the diagnosis ever gets changed to bipolar disorder. Does this make any sense whatsoever? I hate that I have to be afraid to see a psychiatrist, I shouldn't have to worry about a diagnosis.

Anonymous said...

Addendum to my previous post -

I work in the healthcare field but do not have any direct patient care. I still have to answer questions anytime I renew my license, however.

bruises said...

Your part about inter-rater reliability reminded me of this TLP quote from a post he had on borderline from years back:

"This, by the way, is the reason why so many defenders of psychiatric diagnoses can't accept that "borderline" and "bipolar" are equally subjective terms. They say, "the diagnosis of borderline has very poor inter-rater reliability; bipolar has high inter-rater reliability." But reliability is not the same as validity. If you take twenty thousand members of the KKK, and ask them to "diagnose" the problem of contemporary society, their answer will be the same, i.e. reliable. But it's wrong, obviously. The diagnosis of bipolar is reliable, but in the same way as the KKK's diagnosis of society's ills was reliable. It may be completely wrong, it may be completely right, it may be partly right, partly wrong, in some cases but not others, etc."

I think psychiatric diagnoses should be taken with a grain of salt. And I agree that we should measure people based on ability and not on their diagnoses.

Anonymous said...

Jesse writes, "In general, though, and this is true for the various Bar associations, a diagnosis flags an individual for review, not automatic denial."

So, again we are flagging people who had enough sense to get treatment and have not caused any problems. Meanwhile, the ones who are too afraid to seek treatment and or those who don't think they need it can carry on without penalty until they cause problems. I don't think that's the message we want to send. We should worry more about those who need treatment but don't get it.

Skizzy said...

So as a high functioning schizophrenic who is med-compliant and not treatment resistant, I should be able to be a police officer? Would it be ethical for me to take the chance that I don't merge into psychosis under the stress of holding someone at gunpoint? I gave up on my dream and two degrees in the field when I had my first episode. I knew what was wrong with me. Didn't need to pay $300/hr to be told. All he did was agree with me. Guess I should have goneto med school after all .

Je Suis said...


You're right, we probably won't agree. Why is that? I think it's because my beliefs stem from a viewpoint of self-determination, even if that includes suicide, and yours stem from, well, I don't know. It initially appeared to me to be from a sense of kindness, perhaps a real desire to help, but now I'm not so sure. Professional interest maybe?

Anyway, the points: you contend that if I was convicted of an assault charge? Where does that come from? Read what I wrote again: I was the victim, not the aggressor. Besides, there was no police involvement; I wasn't interested in involving them, and the other party wasn't either, for obvious reasons. I dealt with it, end of story. However, I responded to your post because you said "anyone who gets in a bar fight and throws some punches", not anyone convicted of assault. There's a difference, which I attempted to point out. Your statement that "anyone" involved
should lose their gun rights struck me as blaming the victim, since by default the victim had very limited options, basically either defend themselves or be abused. I will always choose to defend myself, and I don't believe I (or anyone) should lose their rights for doing so.

As for the pilot: you then admit that you equate a history involving a suicide attempt with danger? That such an individual cannot be trusted? Why, then, do psychiatrists attempt to save suicidal individuals? Clearly, they cannot be trusted, and their future prospects are now bleak, to say the least. Can't be a pilot, a nurse, or a doctor? A lawyer, or a politician (I assume a politician since, if one cannot interpret the law, then one by default should not create such laws). Hell, they shouldn't be a teacher - can't trust 'em with our children - or even drive a car - plenty of people are hurt or killed in cars.
Really, since they are dangerous, we can't allow then to work in the food industry, even - they might poison a multitude of people. Basically, now that they are dangerous, they can't be trusted to do any kind of work, can they? This is the stigma that the mentally ill have to face, one that you so casually supported in your post; the post of a mental health expert. How, then, can we expect the common person to look past their bias? Answer: we cannot. So, tell me again why we are saving these people who want to die, when even the experts in the field don't truly believe in their recovery? It seem particularly sadistic to me. Offer them hope when you know that there is little to no hope just to keep them alive a bit longer? It makes no sense.

The world apart from psychiatry may have some natural repercussions, but what you are describing is not natural, but man-made. It's a construct, just like society in general is a man-made construct. Which is why a post like this from an expert in the field is so damning. In one fell swoop, you condemn the mentally ill and justify the bias that the more fortunate have against them. Are the mentally ill, even if just depressed, dangerous? Yes, here's an expert that says so. Therefore, it's not a bias, it's a fact. The mentally ill are dangerous, and should be locked away, out of sight, out of mind. Because you never know.

Danger, Will Robinson.

Dinah said...

Je Suis,

I think you misunderstood my intentions and altered my meaning. I know we have international readers, and I am in the United States, so if you are in East Berlin in 1975, please forgive me.

When I said I thought someone in a bar brawl should lose gun rights, I did assume that there would be some form of due process to determine that the person was at fault and that we would not change to a society where one would rat on a neighbor with no proof and that would be taken as enough to revoke a civil rights.

My thoughts on basing job capability on behavior rather than diagnostic labels was meant to free up people to say what they wanted. You could go tell you shrink you're having all sorts of crazy thoughts, he could label it bipolar, borderline, schizowhatever, treat you with the appropriate medications and if either your illness or the medications did not cause your behavior to impair you, then the label or the pills could not be used as a reason to keep you from being a brain surgeon, a lawyer, a bus driver, a pilot. Behavior is different, if you have to be on a medicine that causes a tremor in order to be sane, it's not your fault, but the patient with the brain tumor is entitled to a surgeon with a steady hand. We want to decrease stigma and protect the rights of those with mental disorders, so labels should have no meaning, especially since they tell us so little about any given individual's course and prognosis and what they are capable of.

So the pilot with the recent suicide attempt (not thoughts, not even a gesture of taking a few pills or string up a noose, but an attempt serious enough to land him in a hospital), crashes a plane and kills 250 people. Maybe it's not his fault, or maybe it is, maybe he decided to take everyone else out with him, maybe he was too depressed to react as she should, maybe his medications dulled him, maybe he just didn't care. Or maybe the equipment failed and it had nothing to do with his depression, but the airline will still need to explain to the families of those 250 people that the guy who was piloting the plane had a severe and active mental disorder that required a hospitalization for a suicide attempt and he was the one in charge of your loved one's life. If the attempt was when he was 16, it's different. If it was 5 years ago, maybe we're okay with that. If he had 3 such attempts, all requiring hospitalizations, one 7 years ago, one 4 years ago, one last year.... I don't think the airline wants the liability and the passengers and the families want that pilot. You may not like that, but my Deed, not Diagnosis, is a far cry better then our current system where mental illness ends your career as a pilot, perhaps as a police officer, and requires you to explain yourself on professional licensing boards in some states.

Yes, reduce stigma, but such overseers have a responsiblity to the public as well. I want to move that responsibility to those who deal with the repercussions of troubled behavior and let the patient see a psychiatrist without fears of repercussions for what they say.

As is, a psychiatrist can not reveal what is said except in instances of child abuse or imminent danger. I don't approve of laws that require us to judge dangerous for any purpose other than the best interest of the patient

Okay, I'm tired and done with this topic. I liked Lost in Space.