Saturday, February 21, 2015

Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations?

In last week's New York Times there was an article with a rather interesting title: "Doctors Strive to do Less Harm by Inattentive Care" written by Gina Kolata.  The amazing idea here was that doctors should spend some time listening to their patients (~as an aside, I am so very glad I'm a psychiatrist/psychotherapist), and doctors should acknowledge that people in hospitals may be suffering, not just from their illnesses, but perhaps also from the insensitive treatment that has been inflicted on them such as 4 AM blood draws and unnecessary noise.  Kolata writes:

They found several categories. Communications — for example, a doctor blurting out, “Oh, it looks like you have cancer.” Or losing a valuable, like a wedding ring. Or loss of privacy — a doctor discussing a patient’s medical condition where an adjacent patient could hear.
“These are harms,” Dr. Sands said. “They elicit suffering. They can be long lasting, and they currently are largely unquantified, uncounted, unrecorded.”

So let me tell you why this article caught my attention, and how I'd like your help and input. Bear with me for a little bit here.

As our readers know, we're working on a book, Committed: The Battle Over Forced Psychiatric Care.  In my research on involuntary psychiatric care, and even on coerced care and some voluntary care, I've heard people talk about how traumatizing treatment can be.  Not everyone says this, not even most people, but some people are very sensitive and some care is very callous.  I'm finding that a little of the care is unnecessarily brutal, but this has really gotten so much better in recent years.  People are rarely restrained in your average psychiatric unit (I've been peeking in mostly empty seclusion rooms and asking lots of questions), because regulations restrict this.  But sometimes it really is still necessary; as much as we like to say that psychiatric patients aren't dangerous, some are.  Some kill people, and psychiatric hospitals are not necessarily the safest places to be.  In one forensic hospital in our state, in a one year period, three patients were killed by other patients.  In one community hospital, a patient poked out the eye of a nurse.  Staff are assaulted regularly, and even our own blogger ClinkShrink was punched in the head by a patient who had no prior contact with her and no reason to assault her as she was leaving the unit.  Clink was this patient's second assault victim of the day.

But let's move away from the extreme cases of violence.  Patients are traumatized by more benign things --- being asked to participate in activities that don't feel therapeutic when they are feeling miserable and depressed and would rather stay in bed.  Having nurses shine flashlights on them to tally their hours of sleep.  A lack a of privacy and a constant sense that they aren't trusted.  What? I can't have a belt on the unit?  I like my pants to stay up! Patients don't control the temperature of the rooms, the volume or programing of the TV, what foods they are fed, when they can exercise, when they simply take a walk outside, if they can have wine with dinner, a smoke after, and sex when the urge strikes with an appropriate love partner.  They may not know what the consequences might be for refusing to swallow a medication that makes them nervous to ingest, and there are circumstances where are injected with medications against their will.  They may find treatment to be very disrespectful and very demeaning.

Some of these things have no great answers.  The staff can't magically predict who is dangerous and there are sometimes concessions to comfort and human rights. Obviously everyone isn't held in restraints because of what they might do, and people are allowed to leave the unit and usually nothing bad happens --but believe me, everyone remembers when something really bad does happen.   

Many of the patients leave the hospital so much better.  Their depression has started to lift, their agitation is quelled, they aren't suicidal, they aren't terrified of delusional events that were never happening or hearing voices that aren't there.  They're sleeping and eating better and not so irritable or not so manic as to be uncontainable.  And yet, these so-much-better people, some of them feel so violated and so angry about what has transpired in the name of getting them help.  Maybe it's all a lack of insight, but I want to wonder if it's more than that, and this where I'd like your input.  As with the cancer patients Ms. Kolata wrote about, it's a field with so little research.  People are very different, and we simply don't know who gets distressed and what might mitigate that distress.

This is what I wonder.  Would it help to have an exit interview?  To listen to what of the treatment made patients suffer.  To listen, not to to throw in people's faces that it had to be done because they were embarrassingly out of control, but to acknowledge that the treatment was difficult, hard to endure at times, and to simply validate the distress the patient felt without the assignment of blame to either party?  

I'm going to go one step farther, please hang in here with me.  I recently spent a day with a wonderful mental health court judge.  If you know nothing about mental health court, the short version is that some people with psychiatric disorders are offered the opportunity to plead guilty and participate in mental health treatments, and if they do so successfully, they can avoid serving time in jail.  In some cases, their record can be cleared.  So these are people who have committed crimes, but the team is like a hospital team -- social workers, prosecutors, defenders, the most amazing of probation officers, and comprehensive services are put together to include drug treatment, clinic appointments, vocational rehab, housing, and weekly check-ins with the probation officer who talks to everyone from the patient's psychiatrist to the patient's mom.  It's the legal system taking over a medical role but the person at the head of the table is a judge and not an attending psychiatrist.  I'll tell you that I found it really weird.  And so you know, this is behind the scenes, it's not a public discussion.

Later, however, there is a quick public court hearing.  The defendants come to court once a month (or more) and if all is going well, the court has a celebratory feel.  There's a quick report and the judge congratulations the defendant on a job well done.  There may be applause, there may be certificates, the defendant is asked if he has anything he wants to add, and a subpoena is given for the next month.  These are criminals, and yet their successes (which are simply the lack of more failures and compliance with recommended treatments) are being celebrated and publicly acknowledged. Every few months, there's a graduation ceremony for those who finish the terms of their is served, families come, boyfriends and girlfriends come, photos are taken with the judges.  It's all good, people are happy and they've been given the opportunity to get treatment and turn their lives around.

So would it help when people left a psychiatric hospital feeling badly, violated perhaps, and certainly shamed because this is something we hear over and over even if the patient did nothing shameful at all, if we listened?  What if we acknowledged how difficult it can be to get treatment and participate in it, to let people know what a tremendous job they've done in getting through such a difficult time (even if it wasn't all graceful)?  Would it help to have a celebration when someone was discharged --even if just pizza or cake or something a little healthier, but to bring in family and print up a certificate to be read aloud and not make this all about shame?

Obviously it might be nice, but what I want to know is would there be a reasonable shot that this might mitigate the trauma of the hospitalization?  That it might lessen the sense of violation and reduce the idea that if an illness remitted and another hospitalization was needed, that it wouldn't necessarily be all that bad?  I'd love to hear what you think, and if I'm wrong about this, I'd love to know what you think might make for a easier re-adjustment with less dwelling on the injustice of it all?  And yes, this time, I'm more interested in hearing from patients who've been hospitalized.  Thank you so much.

Sunday, February 08, 2015

On Government Oversight and Caring for the Sickest

This is going to be another post on the issue of "Us" versus "Them" because that seems to be what psychiatry is about these days: civil wars. 

First, I'd like send you over to an article in the Wall Street Journal by E. Fuller Torrey and Doris Fuller: Mentally Ill?  Drink a Smoothie.  Torrey and Fuller run the Treatment Advocacy Center-- it's known for for it's vigorous support of legislation that would increase the use of involuntary care for those with severe mental illnesses.  It's one part of their work, and their overall mission is "to eliminate barriers to the timely and effective treatment of severe mental illnesses."  

Torrey and Fuller write a scathing article about SAMHSA --The Substance Abuse and Mental Health Services Agency-- our government's oversight agency.  They point out that of SAMHSA's 570 employees, only one is a psychiatrist who works with the substance abuse side, not the mental health segment.  They point out that the agency's 41,800 word action plan doesn't include a single mention of 'schizophrenia' or 'bipolar disorder.'  Worse, they describes how there is little or no coordination between programs targeting serious mental illness.  The graphic at the top of this post, by the way, is a children's book funded by SAMHSA.  Your mental health tax dollars at work and I'll leave you to decide if that's how you want them spent. 

Torrey and Fuller write:
 The nonpartisan Government Accountability Office this week released a scathing report on the lack of leadership in the Department of Health and Human Services for coordinating federal efforts related to serious mental illness. It described 112 separate programs in eight federal agencies with little coordination. “The absence of high-level coordination,” the GAO concluded, “hinders the federal government’s ability to develop an overarching perspective of its programs supporting and targeting individuals with serious mental illness.” The report was especially critical of the lack of any formal evaluation mechanism for the majority of the programs, so there is no way to tell whether they are working.

They go on to say: 
Meanwhile, problems related to serious mental illness have continued to get worse. Such individuals comprise at least one-third of the homeless population. And according to our analysis of data from the Justice Department, American Correctional Association and the American Jail Association, there are now 10 times more people with serious mental illness in U.S. jails and prisons than in state mental hospitals. Individuals with untreated serious mental illness are responsible for 10% of all homicides in the U.S. and approximately half of all mass killings.
And what has been Samhsa’s response? In September the agency sponsored a “National Wellness Week” during which it suggested that drinking fruit smoothies and line dancing would achieve wellness. And during last month’s “historic” East Coast snowstorm, SAMHSA opened four hotlines for individuals worried about the storm.

Regardless of your feelings about Torrey's work on involuntary treatment, when it comes to issues of how the government is funding and administering care in a timely and effective manner, Torrey is right: the money could be put to better use, we need more effective and timely --and I'll add kind and humane -- treatments for those with mental illness. You'll note that I have omitted the word 'severe.' 

In another article on therapeutic communities, Allen Frances noted, "Advocacy for the mentally ill has been so ineffective in part because it has so split in the often bitter civil war between the medical model and the recovery model."

So this 'civil war' that Frances refers to has been played out in our federal government.  SAMHSA has largely taken on a 'Recovery model' stance, and not a 'medical model' one.  The Recovery movement is, in part, a backlash to conventional psychiatry with opposition to the idea that psychiatric diagnoses convey hopelessness and are dis-empowering, and that psychiatric treatments have been harmful and disrespectful.    The Recovery folks are worried that those who favor the medical model will de-fund (?un-fund) their programs, and they well be right to worry.  There has been a push-back against the Recovery model from people who note that not everyone gets well and that some people do need a more paternalistic doctor-knows-best treatment model focused on medications and illness.  They further feel that the Recovery model conveys blame on those suffering from psychiatric illness -- if only you tried hard enough (and drank smoothies) you, too, would heal.

There's an underlying civil war going on as well, that sort of falls along the lines of Recovery vs. Medical Model but not exactly.  It's the Robin Hood civil war, held by TAC and D.J. Jaffee's, the one says stop worrying about those with mild mental illnesses, the so-called 'worried well,' and move the resources to those with severe mental illness, a very small but very sick percent of people with greater needs.   

I've made the point many times that there is no Us versus Them when it comes to mental illness.  I've run a survey showing that we don't have a clear consensus on who these mentally ill people are (results here)  and in my satire post last week about identifying the mentally ill for purposes of gun ownership, I noted that they don't wear signs on their heads.  Torrey, however, is a schizophrenia researcher and his interest is in patients with chronic psychotic disorders; these people sometimes do wear signs on themselves -- the layers of dirty winter coats they wear in the summer or those who are obviously psychotic who live on the streets and move in and out of jails and hospitals.  Those are the people he cares about.  The suicidally depressed executive who never misses a beat at work,  who goes for therapy and a Prozac script, then has a full recovery within weeks, and quietly goes about living his meaningful life -- he is not Torrey's patient.  

I'm going to contend that Dr. Torrey is right about much of this.  We need more efficient oversight and we psychiatrists involved at the high levels of administration, and we don't need to be funding hotlines for people anxious about snowstorms -- the truly distraught can call the existing suicide hotlines.  We need to include those with severe mental illnesses and to make provisions to help them lead meaningful lives.  

At the same time, I'm going to contend that we can't be Robin Hood, taking from the not-so-sick (those damn worried well who use up society's resources because they can't pull up their own bootstraps)  to give to the sickest.  If a teenager  commits suicide as an impulsive act because he's upset about a break-up with a girlfriend, he's just as dead as a person with chronic, unremitting bipolar disorder who commits suicide.  Someone can be in a crisis that is not mitigated by psychosis or severe mental illness, and that crisis can lead to inability to maintain jobs or marriages or even life itself.  And while half of mass murders --as Torrey tells us - and 10% of all murders are committed by those people with mental illness, then half of all mass murders and 90% of all murders are committed by people without a diagnosis of a serious mental illness.  It's hard to imagine that someone who kills a group of random strangers isn't disturbed in some way, even if they don't fit into the neat little DSM check-off lists.

We need to end the divide between the Recovery and Medical models and have our joint goal be to help people get better -- on their terms and with engagement and respect, whenever possible.  

We need to have timely and effective mental health services available to everyone in distress, whether or not they suffer from psychotic disorders. Clearly, there are people who come for a session or two and the crisis passes, they get something out of it, and they move on without tragic sequelae.  And there are those who need lifetime treatment with expensive medications, help with housing, regular appointments, case managers, daily rehab programs, and a lot of investment.  They should have that, too.  We have plenty of people to spend money on, but what we don't need is more government officials to administer uncoordinated agencies with costly infrastructure that takes money away from providing services to all who need them.  This needs to be our Us against Them: more care/more research vs. less redundant, inefficient beaurocracy.    I'll leave it to you to decide if a smoothie will help.

Wednesday, February 04, 2015

Links You'll Like

From my twitter feed: 

First, my column on Clinical Psychiatry News expressing my displeasure that APA is supporting The Helping Families in Mental Health Crisis Act. 

Lithium in drinking water significantly lowers suicide risk in men:

Great explanation of NNT --Number Needed to Treat-- versus NNH -Number Needed to Harm.  

Serotonin receptors, explained.   

And the psychiatric quote of the day goes to Allen Frances for, "Advocacy for the mentally ill has been so ineffective in part because it has so split in the often bitter civil war between the medical model and the recovery model."  Read his article about a therapeutic community here, and by the way, I'd like to register to live there -- not as a doc, but as a patient who wakes up to a day of organic farming, exercise, art... sounds nice.  The quote was too long to tweet.
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:

Tuesday, February 03, 2015

Does "coming out" with your psychiatric diagnosis help?

So I'm sending you over to read  a wonderful piece in the New York Times by Scott Stossel,  'Coming Out as Anxious." 

The author wrote a book on anxiety and he discusses with his therapist whether it might be therapeutic to tell the world about his problems -- would it lessen his anxiety if he didn't have to spend so much energy pretending it wasn't there, making excuses, and covering for it?  He tells a good story.  

My psychotherapist, Dr. W., understood my concerns. But he suggested gently, on many occasions, that revealing my anxiety would perhaps dissipate the shame I associated with it. Doing so might prove therapeutic, even liberating. “You’ve been keeping your anxiety a secret for years, right?” he would ask. “How’s that working out for you?”
He had a point. I was still terribly anxious, and often unhappy.
But I would retort that at least I was gainfully employed and not a laughingstock or an object of unwanted pity. Concealing my anxiety was in some sense working for me.

Dr. W. would counter that by sharing what I had gone through, perhaps I could provide solace to some of the millions of other people who suffer from clinical anxiety. Perhaps I could even, as he put it, “write yourself to health.”
In the end, I decided, with considerable apprehension, to go ahead and reveal my own anxiety in the book. It’s now been a year since my book was published. Did “coming out” help?
The short answer is: a little bit, yes. The longer answer is … well, let me tell you a story.

Couch is a series about psychotherapy  .Couch