Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Saturday, June 07, 2014
In the Works, "Committed: The Battle Over Forced Psychiatric Care."
Good morning, I've missed you. Blogging has not been the same lately and I've let some great topics go by.
Let me tell you what I've been up to.
There have been so many things to write about lately, and I will tell you that my brain is just bursting with all the work Clink and I are doing on our new book: Committed: The Battle Over Forced Psychiatric Care. ClinkShrink is doing some of the background stuff, she's being (as always) the forensic expert, she's sweeping up after my grammatical carelessness, and correcting the forensically idiotic things I say. She's focusing on legal cases and a chapter on restraint and seclusion. I'm taking the lead on writing some of the other chapters, and her description of this is that it's like trying to keep up with a hamster in an exercise wheel. That hamster would be me, and I'm having no more luck keeping up with my own thoughts then Clink is, but every now and again, I jump off and take stock. I started with this very funny idea that I would work on one chapter at a time, and that each chapter might take a month. Okay, so some chapters are taking a very long time to get the parties lined up for, and I'm working on 5-7 chapters at once. These days, I'm as much journalist as shrink.
Would you like to hear about the book? Don't hold your breath on being able to read it anytime soon, but it's making progress and some days the progress is much faster than I expected.
The first two chapters are from the perspectives of patients -- wonderful, intelligent, articulate, people -- one of whom found that involuntary hospitalization was traumatizing to her and left feeling her injured, another of whom found it help keep her life from disintegrating. I purposely chose people who had good insight and believable stories -- I didn't want the person who felt her care was unkind to be dismissed; I thought her complaints were valid and warranted a critical look. Both patients allowed me to access their medical records, and to interview their doctors and family members, so I felt like I got a good sense of what went on.
Since the book is "The Battle Over Forced Psychiatric Care," the third chapter is called The Battleground. This is the most difficult chapter to write to date, just because it's taking time to get together with everyone. So far, I've interviewed E. Fuller Torrey of the Treatment Advocacy Center, Ron Honberg of National NAMI, Ira Burnim of The David L. Bazelon Center for Mental Health Law, and an anonymous gentleman from the Church of Scientology in New York City. I have times set up later this month with Paul Summergrad, the President of the American Psychiatric Association, and Daniel Fisher of the National Empowerment Center (a Recovery Group), and I have been working hard with MindFreedom (a survivor organization) to find a time for a conference call. Some other great people have chimed in as well: Xavier Amador, Solomon Snyder, and Paul Appelbaum has been helpful every step of the way.
Chapter 4 is currently on Civil Rights, and it's taken from a news story our readers pointed me to about a woman in Vermont who was held in a hospital for 5 and a half weeks with no hearing. The case is the springboard for discussion, so I've talked with a wonderful legal aide attorney in Vermont as well as the president of the Vermont Psychiatric Society. As in many of our chapters, the laws there are changing as we write and the hamster keeps trying to run faster.
Chapter 5 is on law enforcement and how people enter the mental health system through police interventions. I focused here on Crisis Intervention Teams, and Officer Scott Davis has been a gem to let me ride along with him and share his world with me, and Judge Steve Leifman in Florida has given some wonderful insights and statistics.
Chapter 6 is on the inpatient unit, and the chairman of psychiatry, Dr. Ray DePaulo was truly my hero for allowing me to shadow him on the unit. Steve Sharfstein, a former APA president and CEO of Sheppard Pratt Hospital talked with me about how his institution works, Dr. Bruce Hershfield a former a superintendent of Springfield State Hospital, shared his insights with me, and I had a present-day tour of the state hospital, which now houses 230 people, down from a high over 3,000.
In short, lots of lunches, and lots of insights from really brilliant people.
Clink is working on Chapter 6: restraint and seclusion, and the plan down the line is to look at the legal system through the public defender's office, outpatient commitment, violence and mental illness, guns and mental illness, maybe forced ECT, maybe indefinite confinement of sex offenders (we'll see), and a little more focus on both families and legislation. Jeff Swanson at Duke has provided invaluable guidance, and I've grown very fond of these folks at Penn from The Scattergood Program for the Applied Ethics of Behavioral Healthcare -- and I'm looking forward to spending more time with Candice Player, and John Monahan, once I finish the current chapters and more forward. For my brief blog post, there are many many people missing, but I wanted to give some quick shout outs and just an update on the quite nature of Shrink Rap these days.
What do you think? Obviously our blog readers have been instrumental in shaping in our writing. But if you're looking for a book to either extoll the virtues of forced care or to completely vilify it, you may need to hold back. These are complicated issues and our goal is to talk a close look at involuntary treatment, figure out when it can be made kinder and gentler, and figure out if or where it fits in with psychiatry and/or the prevention of violence.
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Yes, the system seems to work well, even when maximized, hmm?
From one of your favorite sources, the New York Times, yesterday.
Yes, sad, tragic, and why we should have prisons for some first before providers as potential victims second, eh? Not that this situation was about providers attacked, but, when will those stories surface?
Somewhere along the way, our society mistakenly assumed that providing special legal rights (such as mental health courts, case managers, and speedy hearings) would be a good thing for people diagnosed as severely mentally ill.
It's backfired. And has caused a loss of freedom - moving these cases from one of guaranteed equal protection under the law to unequal protection - causing a loss of guaranteed constitutional rights - especially the right to legal representation by an attorney; the right to question accusers (who claim they are an imminent threat); the right to request a jury of peers to hear testimony (rather than have the case determined by mental health experts).
It's a mess. In fact, it's a civil rights crisis:
You should interview Attorney,Jim Gottstein of PsychRights.
You have a lot to learn from him.
You are brave to tackle this issue and I appreciate the balanced approach. I know you will gets lots of criticism but you seem very passionate about it!
i can't wait to read it.
You might want to interview Robert Whitaker. Here is a column he wrote on the MIA site in 2012 that pertains to involuntary commitment when he was taking issue what various points Dr. Torrey had made:
It seems like from your list of interviewees, that your book will include a lot by people who don't believe mental illness exists. You may want to interview more who believe it does. You should also interveiew more police and sheriffs. I would suggest Michael Biassoitt, past president of NYS Assoc. of Chiefs of Police and Sheriff Dart of Cook County Il. They pay the consequences of inadequate civil commitment laws. You may also want to visit some jails and talk to prisoners who are examples of it, and perhaps some famillies. You can learn a lot about the issue at http://mentalillnesspolicy.org/ Good luck with your book.
I think we can all agree on one thing: It's a mess.
I think we're doing okay getting a balanced view here. Interesting who has been eager to talk to us and who who is very hesitant -- it is about a dialogue and I've been surprised that the dialogue is not always easy to come by.
While I'm agreeing to present peoples' views as they'd like them presented, I can't absolutely agree that in the end, I'll draw the same conclusion as any given person or group would want drawn. This bothers some, not others.
DJ: NAMI, Torrey, APA, CIT officers, Judges, Dr. Applebaum, Dr. Sharfstein, and the list goes on and you don't think I have people who believe that mental illness exists? Give me a break.
Psychrights: Gottstien's on my list, but it's a long list. Fisher, Saks, Delano (MIA).
I'm having a very hard time getting together with MindFreedom, I've been trying for many months and they finally offered a time for a conference call last week, but I couldn't make it. If anyone knows a "Survivor"'s group that would like to weigh in, I'm open to suggestion. Whitaker is a journalist, not a survivor, and I've read Anatomy of an Epidemic very carefully, even called one of the main researchers he quotes, and I find his logic to be flawed. He tells a compelling story, and there may well be elements of truth in it, but his argument is one of correlation and anecdote and doesn't hold to scientific rigor on its own.
On Bob Whitaker's Anatomy of an Epidemic, apparently you missed Tom Insel's post last year on the overuse of neuroleptics. In case you missed it, here it is
"It appears that what we currently call “schizophrenia” may comprise disorders with quite different trajectories. For some people, remaining on medication long-term might impede a full return to wellness. For others, discontinuing medication can be disastrous. For all, we need to realize that reducing the so-called “positive symptoms” (hallucinations and delusions) may be necessary, but is rarely sufficient for a return to normal functioning. Neither first nor second generation antipsychotic medications do much to help with the so-called negative symptoms (lack of feeling, lack of motivation) or the problems with attention and judgment that may be major barriers to leading a productive, healthy life. Family education, supported employment, and cognitive behavioral therapy have all demonstrated efficacy in reducing the likelihood of relapse events, increasing the ability to function in daily life, and improving problem-solving and interpersonal skills."
And this is a comment featured by The Guardian in a recent story about forced treatment,
"I'm a young shrink, naive maybe but I already know the system needs major reforms.
My in patient facility that is responsible for around 100,000 citizens has 16 beds. If I fill them all my next admission gets shipped half way across the state.
Both public and private funds dried up when they realized the black hole mental health was. Not only was our clientele typically poor but they noticed most of our patients would stick around for years. This was in the sixties, soon they were pulling funding and both the gov and private business's started pushing my fellow shrinks to diagnose, prescribe and let the family deal with day-to-day costs. Not only that, but docs and hospitals were liable if the patient hurt themselves under our care. Suddenly we needed an entire fleet of nurses and orderlies just to stare at them.
I quickly learned that as a psychiatrist if I really want to help people out-patient is the way to go. It has it's own hurdles but benefits too. Like: the mentally ill are typically happier surrounded by family than they are locked in a room where nurses peek in every 20 minutes.
You see the lack of public beds isn't just because of money. But a shift in philosophy, your mentally ill family member will recover faster, if possible, surrounded by loved ones than in a sterile room gawked at by strangers. If that is a burden to you, I completely sympathize but in all honesty a nursing home is not a bad option at that point. The 16 beds are there for the mandated and the other few who genuinely need a few days to gather themselves and learn some therapeutic coping skills. Eventually returning to their loved ones. Our goal shouldn't be a return to a lifetime locked in an asylum.
Does anyone really think forcibly restraining then injecting a patient is going to help them heal faster? After the first time you've destroyed all trust with the patient and now she hates and fears the scary people in white coats now you want her to spend the rest of her life confined and surrounded by them?
That's not healing that's torture!
I am the first to admit that schizophrenics are difficult to keep medicated but 95% of them are perfectly benign without it. Heck, i met a Harvard educated pediatrician who is pschizophrenic.
A far better option is explaining why they need the medicine and developing a level of trust and wiping away the stigma. Yes you will have to do this many times, but they're worth it.
In my entire career including school I've only had to have one patient forcibly restrained. That was the worst day of my life, I felt like an utter failure. If that traumatized ME that badly just imagine how the poor guy with 4 linebacker orderlies dog piling him felt!
No, we have to understand that 99.9999% of the mentally ill are harmless and not stigmatize them for that .0001% that aren't. Don't add more anxiety to their lives by having a judge mandate their treatment. Talk to a psychiatrist instead! She's sick, not a criminal!
Anyway, I kind of got off track but I hope a few people realize that we didn't pile up enormous debt and spend decades in school just to write Rx We did it because we wanted to be shrinks and we knew way ahead of time our patients were poor and vastly underserved and needed help."
That is too bad that Mind Freedom can't be more flexible regarding meeting with you. Anyway, the Icarus Project might be a possibility. Here is the contact information:
Not a criticism, just a comment: I think the vast majority of more typical patients are being left out. Those who are articulate interviewees tend to be well educated people from better off families, at least those that have commented here on Shrink Rap have been. Most of the people that I know with serious and persistent mental illness got sick when they were in high school, and therefore often didn't finish school and certainly had limited if any college or vocational training. The vast majority of doctors and policy makers come from a privileged, educated background, and plenty of psychiatrists do not take medicaid and hear the stories of those who have chronic and severe mental illness. Try interviewing in a drop in center in a low income area - that might be an eye opener. I certainly read and hear a lot of clueless comments from folks who have never been poor, other than the short term, not really poor that a person experiences in college. And of course, with all that fancy education, they all can advocate well for themselves.
Iluvcats -- this is a great observation, and so accurate. Many of the people who are committed are very sick, under-educated, poor, and not activists or advocates. Many are used to being shunted around and powerless -- perhaps from their mental illness, perhaps from their addictions, perhaps from their poverty and general oppression that comes with lower socio-economic status that people with schizophrenia often land in. They go in and out of hospitals and jails, and when they come to their clinic appointments, they often don't have a lot to say about their forced care. One of my patients used to just say her family was crazy and there was nothing wrong with her (and her family was pretty disordered, the main informant being the heroin addicted son who'd finished out a murder sentence). They don't end up dwelling on the unfairness of it all (in part because their whole lives have been unfair), or becoming focused on this.
The book is focusing on those with strong voices because there's not much mileage in Sam was committed 4 times, when asked he said it was wrong and unfair, but if he wasn't asked, he didn't say much about it.
DJ Jaffee (aka, Mental Illness Policy) makes the rounds.
Whenever there's an opportunity to strip the "mentally ill" of due process, Jaffee is there.
Here's a video worth watching, DJ:
The Illegaility of Imprisonment, Forced Drugging and Forced Electroshock in the US - by Attorney Jim Gottstein:
We're on to you, Jaffee.
The Illegality of Psychiatric Imprisonment....
Dinah, I know you have alot to cover so forgive me for mentioning this. But due to concerns about metabolic issues that I am seeing my PCP about, I wonder about the legal issues involved if someone is forced to take meds and develops diabetes or some serious side effect.
Hi, stranger. I hope that in your book you will also focus on the absurdity of spending such time, attention, and money on involuntarily treating people who don't want it, while comparatively less effort is being placed on getting treatment for those who do.
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