Monday, March 17, 2014

In Their Shoes

There was an op-ed in the New York Times recently by the Executive Director of the Colorado Department of Corrections about the 23 hours he chose to spent in solitary confinement (ad seg, I think is what our forensic friends call it) --- see "My Night in Solitary Confinement."  

In a similar experiment, psychiatrist-blogger Simple Citizen spent a day going through the motions of being a patient on a Residential Treatment Unit where he is the psychiatrist.  He details his experiences in "My Day as a Patient."

I don't believe these experiences are anything like the real thing, nor do I believe they are meant to be.  For one thing, the person having them has not gone through the lifetime of events, traumas, distresses that led the inmate or patient to be in those places.  Or in the case of the patient, the doctor also is not experiencing both the internal discomfort that comes with the mental illness, or the side effects which come with the medications, or the emotional upheaval that comes from having been left there by their family, and the insecurities that come with being a teenager or any brand.  And they both get to go home.  Why, Dr. Simple Citizen, do the kids have to stand on line facing straight ahead without talking while they wait for breakfast?  What's wrong with talking?

Still, I like that these people did this, it's good that they want to try to understand what their charges are going through.  Even if it's not a complete understanding, it still acknowledges that the condition is different with a willingness to see and understand what the other is going through, for better or for worse.  

On a completely different note, Simple Citizen pointed me to his post by mentioning in our comment section that he used to work at an involuntary state hospital.  What's an involuntary hospital?  I ask because Clink has pointed out to me that the rates of patients in public facilities varies greatly, state by state, for involuntary hospitalization.  Wait, so there are facilities that only take involuntary patients?  In our state hospitals in Maryland, at this point, the vast majority of beds are for forensic patients-- you get there by way of a judge.  If you have a chronic, severe psychiatric disorder requiring long term treatment which you'd like to get voluntarily, you're out of luck, we don't do that.  Or if you have a chronic, severe, intractable condition which makes it so you can't live in the community, you may have no where to go.  But when we did have state hospitals, many of the patients were there voluntarily, and some got better and discharged in a matter of weeks.  So I'm perplexed about a hospital that only has involuntary patients, what if they want to sign in?  Help me out here, Simple Citizen and others.   


Jjoel Hassman, MD said...

"If you have a chronic, severe psychiatric disorder requiring long term treatment which you'd like to get voluntarily, you're out of luck, we don't do that. Or if you have a chronic, severe, intractable condition which makes it so you can't live in the community, you may have no where to go."

Probably the two most frightening sentences one could write who participates in mental health care, irregardless if patients or provider. Imagine telling people with chronic medical problems they could not go to a hospital for teritary care treatment that could not be responsibly provided in an outpatient setting.

And, all the physicians and other influential parties who have allowed the co-opting of state inpatient facilities just to become forensic extensions of Perkins Jr, the Third, et al., where are their souls these days?

Just curious to any provider reading here, if you had a loved one who needed long term inpatient care and could not afford a Sheppard Pratt private stay, and your loved one ended up at Springfield or Finans and then was brutally assaulted by a forensic patient who had to be "transferred" from Perkins as their length of stay was up, but yet not ready for the community, how would you feel.

Probably not going to be a chapter in this book, eh, ladies?

Oh, and this above example happened to a patient while I was at Finans a few years ago. Yeah, I get it, bureaucracy can't be changed overnight.

But, with the cretins we have in entrenched power in Annapolis and their extensions in positions of authority throughout the state of Maryland, you really think there will be a chance for honest and effective change?

You wrote those above 2 sentences I copied for this post, not me.

Simple Citizen said...

For clarification - I worked at a hospital where about 90% of patients were on 72 hour holds or had been committed by the court.

Voluntary admission was possible, just very unusual.
(I also took plenty of people off of legal holds because they didn't meet the criteria in the first place)

There is a place and a need for involuntary hospitalization as well as court ordered medication.
There are people who do not "in the moment" have the ability to care for themselves or are an imminent threat to themselves or others. These are not criminals, or terrible people, nor are they to be ignored and left to their own destructive devices because they are mentally ill.
The involuntary treatment system exists for a reason - to help the mentally ill in a moment of crisis or decompensation.

HOWEVER- With involuntary treatment there is also a horrific opportunity for abuse of power. I see it every day.

The answer is to fix the system, not demonize and abandon it.

Anonymous said...

Simple Citizen: Although, it probably isn't something you could pull off, let's imagine you could get a colleague to "commit" you for 72 hours (without telling the nurses and other staff that you were not an actual patient. Taking into account all of Dinah's caveats, you would get a better picture than you did by spending the day with your own patients and colleagues in your own workplace. They knew it was a game even if you had good intentions. Hopefully, you never have to experience the real deal.

Anonymous said...

Simple citizen,

I am very happy to read this. I almost missed it because the only reason I came to this blog was to provide feedback on so called "involuntary commitment" led by Pete Early who is a well known promoter of involuntary treatment beyond what our current legal protections allow. I described the policies that Pete defends as "psychiatric abuse". Defenders of said policies usually get upset when I describe them in such harsh terms, and I always tell them that they should give it a try to being at the receiving end of said policies before making a judgement.

Something that I might have missed in your write up is whether during your 14 hour "experience" you were given drugs, especially drugs against your will.

I will complement your experiment not only with a longer stay as some other commenter suggests, say 1 month, but with taking during that stay 20 mg of Zyprexa each day (which is guaranteed to result in metabolic problems) combined with some other psychiatric drug of your choice (since polypharmacy is standard practice nowadays in psychiatric hospitals).

In fact, I would require every defender of psychiatric power, such as Joel or Pete, to go through that experiment before they have any kind of moral right to be upset with my description of AOT and other involuntary measures as "psychiatric abuse" :-).

Anonymous said...


Where it says,

"I will complement your experiment..."

It should say,

"I WOULD complement your experiment"

Anonymous said...

I am the first anon. I would not wish any psych drugs on Simple Citizen. I was trying to say that his experiment wasn't terribly impressive, given the fact it was really more of a game and the kids and staff 'played' along. It crossed my mind that if my doctor did this, I would feel mocked, and that may be have been a form of abuse of power if you think about in a certain way. I can also choose not to think about it in that way, as I'm sure Simple Citizen had good intentions. However, I do think that this act had the potential to send some unintended messages and it is important to remember that SC was not the only one affected by his decision to play patient for the day. It's an interesting topic, which I shall leave for now.

Anonymous said...

I definitely agree that Simple Citizen's experiment falls short even though his intentions were excellent. I agree with the suggestion that he should have been admitted to place where no one knew whom he was and placed on a psych med cocktail for 30 days. That would have given him a true sense of what patients go through.

Ok, back to reality. Simple Citizen, I posted this in another blog entry on SR but it bears repeating:

It is by a mental health counselor who used to work in psych hospitals. He excellently points out that as long as the one size fits all drug treatment continues to be the standard of care, nothing will change. It is an excellent reminder about the definition of insanity which is doing the same thing repeatedly and expecting different results.

I also have a different take on your point that someone who can't take care of themselves is mentally ill. There could be various medical reasons why that is the case, particularly severe sleep deprivation that has nothing to do with having mental illness.

Frankly, it greatly frightens me that you would assume everyone in a specific situation is mentally ill without suggesting further evaluation. This would then sentence someone needlessly to a lifetime of drugs with horrific side effects with the underlying condition untreated.


Anonymous said...

I think it's great that Simple Citizen wanted to try and see what it was like to be a psych patient; however, you really cannot get a feel for what it's like unless you've actually been in those shoes. You cannot know the terror that comes with not knowing what can be done to you, what's going to happen next, can they legally force medication? Can they force ECT? Imagine how terrifying it is not to know those things and to fear that they will be done to you.

Imagine waiting in the ER for 9 hours in a room the size of a closet with a metal door and mesh covering a window on the door without any food or water.

Imagine that after 9 hours, you are told that if you don't cooperate with the EMTs that are there to take you to the psych hospital that you will be tied up.

Imagine getting to the psych hospital, 9 hours later, still no food or water and being told that if you don't sign the informed consent and agree to hospitalization that it will be more difficult to get out. Imagine knowing that this is nothing close to informed consent and being aware that the staff know it, too.

Imagine being terrified because you don't know how long you can be held against your will (they don't give you your patient rights until after you're admitted and off to your room).

Imagine you are forced to strip as a voluntary patient who is really involuntary and told that if you don't they will make you. Imagine standing there without any clothing, think of how humiliated you feel.

Imagine after 9 hours of no food or water, being forced to strip, then made to do the mental status exam and answer questions like "what would you do if there is a fire in a theater," and "please spell the word world backwards," and on and on and on when all you want to do is have a drink of water and go to sleep.

Imagine asking a nurse if there are patients there who have been convicted of sexual assault. The nurse tells you she cannot answer that, which of course tells you there are. Imagine knowing you are going to be in a room by yourself that night, without a lock on the door, and wondering if you screamed if a nurse would get there in time to stop a sexual assault. Imagine staying awake all night, just in case you have to defend yourself.

Imagine how scary it would be to not know when this would all end.


Simple Citizen said...

To Pseudo-Kristen and multiple anonymous writers:

You are exactly correct - my experience was very little like what patients experience.
I have not had to suffer with mental illness, I knew the whole situation was fake, others treated me differently because they knew who I "really" was, I did not take medications, nor was I asked to. I knew when I was getting out. I was not strip searched, I did not have to go through an ER or an ambulance ride or explain to my family or meet a new therapist or get along with a roommate.

There is no way to have perfect empathy without experiencing things for real.

My purpose was
1: To see what parts of the day seemed useful and what seemed arbitrary, useless, or detrimental.
How are the school classes, the groups, the rooms, the rules, the techs, etc...

2: See if I could feel any of the vulnerability, the fear, and other emotions inherent in residential treatment.

I recently read very disturbing books by Ellen Hopkins about teenage meth use and incestual sexual abuse. I didn't enjoy them, but I found them helpful to better understand my patients. As I read them I asked a mentor of mine "Is is worth it to read these disturbing books to better understand my patients? Where is the line? I'm not going to go use drugs to develop empathy for my patients who use. I'm not going to take antipsychotics either. Apparently I am going to read disturbing books by those who have experienced it. Is that good, bad, or helpful?"

His answer was: "You need to do enough to have empathy, that's where the line is."

I am simply trying to get a glimpse; some way to know a little bit better what it feels like to sit in the other chair.

Anonymous said...

To the moderator, I made a mistake and posted the same thing in the "psychiatrists are evil" entry, please ignore that one.

Simple Citizen,

To add to what the other anonymous have said, I have to say that even if your were able to simulate the whole thing faithfully as humanly possible (including the restrains, the waiting time in the ER, the forced drugging, etc), you'd still not know this.

Although the author concedes that,

"2002 UPDATE
"The ADA [Americans with Disabilities Act] was passed in 1990, prohibiting employers from discriminating on the basis of disability, including mental disability. Employers may no longer ask applicants about their mental health and hospitalization histories. ... The best the ADA has been able to accomplish is to change the workplace from one where applicants had to affirmatively lie about their psychiatric histories and diagnoses to an environment of 'don't ask, don't tell.' ... when it comes to psychiatric disabilities, it would be fair to conclude that the ADA has failed to provide a remedy against employment discrimination." Susan Stefan, J.D., Hollow Promises - Employment Discrimination Against People with Mental Disabilities (American Psychological Association, Washington, D.C., 2002), pp. xiv & 19-20. Susan Stefan is an attorney at the Center for Public Representation in Newton, Massachusetts. Until 2001, she was a professor of law at the University of Miami School of Law, where she taught disability law and mental health law. She graduated magna cum laude from Princeton University in 1980, received a master's in philosophy from Cambridge University in 1981, and received her law degree from Stanford University."

the reality is that the moment somebody is assigned a DSM label, that is the moment that person is stigmatized for life. And the reason the stigma exists lies in the scaremongering campaigns that organized psychiatry regularly engages in, like when they put their propaganda machine at work to advertise about the "dangers" of untreated so called "mental illness" and the need to pass AOT laws to clamp down on people who refuse "treatment" (ie, drugging).

The biggest favor somebody like you could do to somebody like me is to jump ships to join the anti psychiatry movement.

Until that happens, you are still promoting "mind tyranny". With better manners than somebody like E Fuller Torrey perhaps, but it is still tyranny.

Anonymous said...

Simple Citizen,

I think it's commendable that you are trying to understand what it's like for patients.


Nathan said...

Simple Citizen,

Would it be more useful to just ask the folks in your hospital "what parts of the day seemed useful and what seemed arbitrary, useless, or detrimental?" The parts of the day may seem a certain way to you, whether you "participate" in the day-in-a-life experience or not, but your experience is not the experience of the patients. Can you have a survey/interview? Can you pay people for their feedback? Can your program take that feedback seriously and have the mechanisms to make meaningful changes to program if indicated by the feedback? I would suppose feedback from patients will tell you more accurately about the usefulness/harm of what happens in the hospital than your own attempts to feel out the day as a pseudo-patient. Your idea of what's important, helpful, or harmful may be very different from what the people you are trying to help think and certainly comes with biases. If you are really looking for outcomes--patients experiencing benefit--their experience is what matters, not yours.

As for part two. Why would you want to feel the vulnerability and fear inherent to residential treatment? If it is inherent, what can you do about it? Be (more) empathetic? That rings hollow to me. I will speak for myself that I don't feel any less scared or more secure in dangerous/uncertain environments that I am coerced to be in because someone who works in that environment can relate that to me. I imagine it would make me feel resentful that such person is aware enough to recognize the absurdity of the experience and mistrustful/sad that such person fully participates in it and won't/can't change it.

As an aside, a few weeks ago I had to pick up a sibling for the Psych ER. Without going into details, the whole experience seemed pretty arbitrary and unhelpful (my sibling would have more descriptive words). Accused of not taking meds, but not allowed to take meds (or food or water or coffee or nicotine patch). Because of a psych label, hold was justified on history of label and not on dangerousness or self-care issues (which I thought was what had to be determined to justify a hold). Staff calls/interviews in-person family to get more information, but does not take information very seriously because we have not seen the family member in a week. However, a few phone calls to random and unreliable/unstable friends who have seen family member more recently were highly considered for justification for release. Utilization of low-cost hospital clinic pushed, but charged large amount of money for unnecessary forced hospitalization. My sibling did not learn anything but (I’ll paraphrase) the "ignorance and callousness of hospital staff who imprisoned me,"to make no attempts to connect with or relate your feelings with staff, and to more seriously question the value and meaning of his years of prior treatment. How was this experience supposed to be helpful?

Nathan said...

I will also add that my sibling as a young teenager spent 6 months in a residential program, where my sibling's life as a psychiatric patient started. It was also rife with abuses of power, arbitrary rules with seeming intention to terrorize/confuse, and leveling system that created hierarchies of power among patients themselves.

Anonymous said...

I keep reading about people being held without giving them water. Does this happen, and if so, why?

Anonymous said...

Anon, it absolutely does happen. I guess they are so focused on other tasks that they forget the basics - like water. I did ask, however. It took 11.5 hours under their care before I ever got a drink of water.


Joel Hassman, MD said...

Maybe this matter with Justina Pelletier is better discussed at this recent post than the newest about "Nice Doctors". Found this link today and think it lays it out nicely:

So, as I said yesterday at the thread of the other post, this is a wonderful example of bureaucracy and, in my opinion, outwardly evil people who are just out to exert control and dismiss debate and dialogue, and use the courts to floridly and harshly be punitive and damaging.

Which is why I inherently do not like the idea of enforced outpatient care be dumped on any community mental health program not outwardly interested in taking on these cases. It has to be done in an enclosed system.

Again, a chapter nicely placed in your lap for your book if really interested in examining this issue as an unbiased and objective source. Or, is that the agenda of the book?...

Anonymous said...

"Anon, it absolutely does happen. I guess they are so focused on other tasks that they forget the basics - like water. I did ask, however. It took 11.5 hours under their care before I ever got a drink of water."

PK, if this happened to a "regular" patient, hie/her complaint would be taken very seriously. But if someone with an ""MI" label complained, it would be blown off and blamed on their mental illness.

People with an MI label are the last group of folks in which it is acceptable to provide substandard care at hospitals. And no one seems to give a damm.