Tuesday, April 28, 2015

Some thoughts on Authority and Victimization

This is our blog, and it's my place to vent some, and on this beautiful morning in Baltimore with all the trees in bloom in pink and white, I could really use some space to vent.  While none of us were in the middle of the unrest, it is awful to watch our beloved city on CNN -- this isn't how it should be.
I'm not going to write about riots or police brutality, but I do want to write a little about authority and  victimization, and for that I'm going to ask you to surf over to my friend Pete Earley's blog where he talks about a psychiatric patient who was arrested after biting a nurse in an Emergency Room.  And Pete is my friend, but I may not be gentle here, but I'll trust that he'll still be my friend even if we don't agree about everything.

Before I start, I want to make it clear: I oppose violence of all kinds by all people.  I strongly oppose police brutality, and I strongly oppose  throwing bricks at anyone or destroying businesses and property.  Let there be peace in Baltimore today and tonight and for all days to come. 

  #Black lives matter.  #Blue lives matter.  #Patient lives matter. #Nurses lives matter
 # All lives matter. 

So Mr. Earley wrote a post not long ago titled  We Took Our Daughter to the ER for Help. She Ended Up Being Arrested. 
     A parent writes in:
My daughter was then informed that she was going to be involuntarily hospitalized. She became even more agitated and when she threatened to leave, a nurse confronted her and a scuffle broke out. My daughter was forcibly restrained by five hospital personnel.
The nurse prepared an injection to calm her and my daughter, who was terrified, said: “’I’ll take the pill. I’m scared of needles.” The nurse proceeded to give her the shot anyway and my daughter would later tell us that she went black.
The nurse was pushing her elbow into my daughter’s chest and our daughter bit the nurse’s arm. She didn’t break the skin and there was no blood. 
Our daughter was put in restraints. Her arms and legs were all restrained, so tightly that her hands began turning purple. I thought things couldn’t get worse but they did. Two officers showed up at the ER to arrest my daughter for aggravated battery against the nurse.

The parent continues -- she's angry that the charges weren't diverted to a mental health court because the nurse wouldn't agree to this.  The parent is distressed and doesn't feel her daughter should be criminalized.

When you look at it, this post is rich with material on so many levels and there are so many things to take issue with.  I wasn't in the room, so I don't know if there wasn't some kinder and gentler way of dealing with this patient besides restraining her, injecting her, and escalating her fear and anger.  And really, if the story is accurate, then perhaps it would be reasonable for the patient to plead self-defense, or to press charges herself for the brutal treatment she received (I have no idea if a patient can do that).  Here, however is what Mr. Earley has to say:

"It is even tougher to understand why some victims insist on pursuing charges when the infraction seems so minor, as it appears to be in the case of the nurse who was bitten."

I, like Pete, believe that people in authority need to have special training in dealing with difficult populations and that people should not be unnecessarily provoked.   But we know nothing about the nurse besides the fact that she went to work, did her job (for better or for worse) and was bitten.  I don't know that the right answer here is to press charges, but I also know that it's not reasonable to tell people they need to go to a job every day where they must tolerate being assaulted without any recourse.  Perhaps the nurse had been assaulted numerous times -- mental health staff often are --  and this can lead to a traumatized staff.  I heard one story recently about a psych nurse whose eye was poked out by a new patient on a unit with no warning (~not in the course of restraining someone) by a patient who had a history of violent crimes.

I don't have an answer for this.  People get angry when they are mistreated, and as a society, we've become sympathetic to the victims of an aggressive authority and some people have decided that the resultant violent  response is understandable.    But the assumption is that the person in authority should be focused on doing the exact right thing, even if it means tolerating a work environment where they are in danger, often repeatedly, and that's just part of the deal.  The story above is told from the patient's perspective, not from the nurse's, and her side is dismissed for her lack of understanding and for insisting on pursuing charges for a minor infraction.  The assumption is that those in authority are somehow immune to the traumatization, fear, exhaustion, and if not, they should stay home or find another job.  And actually, perhaps someone who's sticking their elbow into a patient's chest should stay home, but then again, it's a third hand account and and we don't know the details of what transpired in the heat of the moment.

What's my point?  Simply that we're all human and perhaps these stories need to be heard from all sides before judgement is passed.  Perhaps if we could hear from the nurse, we might understand why she insisted on pressing charges, or perhaps we still might think this too extreme a response.  But it does nothing to encourage people to go into the field if you make the statement that they'll need to tolerate human biting without recourse.

Please don't read this as the idea that I'm condoning brutality by anyone.  I'm a huge proponent of kinder, gentler care, and I'm totally opposed to anyone biting nurses.  Some stories, however, lose something when you only hear one side. 

Monday, April 27, 2015

Involuntary Commitment and Suicide: Looking for Stories

As our regular readers know, we are working on a book called --at this moment in time-- Committed: The Battle Over Forced Psychiatric Care.  We're trying to focus on stories and as many people know, suicidal ideas and behaviors are one reason why people get committed.  I'm looking for one or two stories for our chapter about the experiences people have had with forced care and the spectrum of suicidality.  In particular, I'd like to hear from people who feel an involuntary admission helped them or a family member to get much needed treatment.  As always, however, I'll take what I can get.  Please feel free to comment below, or better, shoot me an email at shrinkrapblog at gmail dot com if you'd be willing to share your story in a book.  Obviously, we won't be using patient names or identifying information. 

Tuesday, April 21, 2015

The 29th Annual Mood Disorder Symposium at Johns Hopkins

Today I went to the 29th Annual Mood Disorders Symposium: Back to the Basics.  I somehow have missed the first 28, but this one was really excellent.  Let me give you the quick recap:

Karen Swartz, MD talked about "Reasons to Still Love Lithium."  The upshot-- it's very effective in treating and preventing manias and hospitalizations, and it has some anti-suicide properties that hold even for those people where it's not terribly effective as a mood stabilizer.  It works for depression as well.  You need to monitor kidney and thyroid function.  It doesn't work for everyone and everyone doesn't tolerate it.   And we're still learning how to best dose it.

Rosalyn Walker Steward, MD, MS, MBA talked about "The Recognition and Treatment of Depression in Primary Care Settings."  She discussed how most depression is treated in primary care settings and discussed the differential diagnosis for major depression versus grief/demoralization and how a primary care doc approaches diagnosis and treatment.

Lisa Townsend, PhD gave a quick introduction to "Dialectical Behavior Therapy: The Basics and Beyond."  She focused on the importance of recognizing and validating the patient's emotional experience.  

Mr. & Mrs. Jones talked about the patient's perspective of depression.  I have to say, I love when successful people talk about their struggles -- it does so much towards getting rid of stigma.  When psychiatrists and politicians talk about the need to decrease stigma...well, I find it a bit hollow.  So Mr. Jones is very articulate, and very successful despite his difficulties with major depression.

Kay Redfield Jamison, PhD gave a talk called "Writing a Life" and talked about the research she's doing for a book on poet Robert Lowell.  She always has interesting stuff to say.

And finally, poet/historian/atheist Jennifer Michael Hecht, PhD talked about the history of suicide and how she has been impacted by it.  

Some quotes I liked: 

Dr. Swartz: "If someone is taking lithium, you want them to be a partner with you in their treatment." 

Dr. Steward: "SIGECAPS"  Really, there's a mnemonic I'd never heard of?  To assess for major depression: Sleep/Interest/Guilt/Energy/Concentration/Appetite/Psychomotor changes/Suicidality.  It needs an "L" for Libido.  Or two "S's" for  Sex.  

Dr. Townsend: "Your response is understandable and real but it isn't getting you where you want to be." 

Dr. Jamison: "People get treated but they don't necessarily get healed."    It might have been worth the whole day for that one sentence.  

Dr. Hecht: "Poetry is the queen of places to expore new ideas."

Save the date for the 30th Annual Mood Disorders Symposia: 
April 19, 2016.

Thursday, April 09, 2015

Out of Network Care : Why?

I'm still thinking about what I'm going to say in my talk about value in psychiatry from the patients' perspective.
It seems to me that the question of value and getting one's money worth might include the fact that the cost is different in different settings.  So someone who gets care at a student mental health center, a VA facility, or a public clinic may well pay nothing.  And in private practice, many psychiatrists don't participate with insurance plans  and people may choose see a psychiatrist when they have no out-of-network insurance, and thereby assume a cost of hundreds of dollars per session.

So my question for now is quick, and again, it is meant only for people who have been patients.

Why do you see a psychiatrist who is not in your insurance network?  If this costs more than going with an in-network psychiatrist, what makes the extra cost worth it?

Wednesday, April 08, 2015

Do You Google Your Psychiatrist?

In psychoanalysis, one of the important principals is that they analyst is a so-called 'blank screen' for the patient to project his/her issues on for examination.  It requires that the psychiatrist remain a bit anonymous, and from this we have the tradition that the exchange of information goes one way in psychotherapy.  There are other, more bland reasons for this as well-- the therapy should be about the patient and the sessions should not be about the psychiatrist, and the doctor is entitled to  privacy.  Different psychiatrists address personal questions in different ways, and I'll tell you that most of the time, I just answer them. I'm neither a psychoanalyst nor a blank screen.

The New York Times opinionator section has an article called -- you guessed it -- Do you Google your shrink? which talks about how Google and the internet have changed the practice of psychiatry.  Blank screens are no longer an option, and Ana Fels writes:

I knew my psychiatric practice was forever changed the day a patient arrived with a manila folder stuffed with printouts and announced that it contained the contents of a Google search that he had done on me. He pulled out a photo of my mother and me, age 7, that had been published in my hometown newspaper; architectural plans for an addition to my house that was never built but apparently was registered locally by the architect; an announcement about my great-grandfather’s becoming editor of Amazing Stories magazine in his old age; and my brother’s history as a college activist.

People are funny in what they want to know.  One patient Googled me before our first meeting and found a review I'd written of a novel on Amazon.  She liked the novel, too, so she decided I must be okay.  Hiding isn't an option anymore.  And patients often know that I write.  I've had Shrink Rap quoted to me.  And the truth is that I am who I am, I can't live my life in hiding or give up writing, blogging, or tweeting because someone might learn something about me. 

So do you Google your shrink?  And what interesting things have you learned?

Tuesday, April 07, 2015

Responses to a Short Survey on Inpatient Psychiatry

147 responses


Was being treated on a psychiatric unit helpful to you?

Yes, I was better at discharge5738.8%
No, I was the same or worse at discharge9061.2%

Were you admitted as a voluntary or involuntary patient?

I entered as a voluntary patient and my stay was helpful3121.1%
I entered as a voluntary patient and my stay was NOT helpful4127.9%
I entered as an involuntary patient and my stay was helpful2919.7%
I entered as an involuntary patient and my stay was not helpful4631.3%

Was your treatment abusive in any way?

My treatment was kind and respectful to a degree I found reasonable and acceptable5336.1%
I felt I was physically abused by the staff1610.9%
I was verbally threatened by the staff4127.9%
I was treated by staff in a demeaning manner without an obvious reason8457.1%
I was assaulted by another patient96.1%
I was threatened by another patient2416.3%
I was physically uncomfortable because I was denied access to food or restroom facilities in a timely manner2114.3%
I was uncomfortable because I was not permitted to smoke.96.1%


When I left, it was clear where I would go for follow up and when7853.1%
I left with no clear follow up appointment or plan4329.3%
Upon discharge, I was given prescriptions for medications I was able to obtain5336.1%
When I left I was given prescriptions for medications I could not afford117.5%
My prescriptions lasted until I had an outpatient appointment3221.8%
My prescriptions ran out before my outpatient appointment1610.9%
I never went to any followup1711.6%
I never filled my prescriptions138.8%
i've been discharged to a safe house
I was released with the drugs
It's been 5 months since my hospitalization and I still haven't been able to meet with a case manager. It took 2 months for them to call me and they have rescheduled twice at the last minute.
price of prescriptions almost $400
Due to holidays and no case worker I didn't see anyone until about 6 weeks after discharge.
The meds were so costly, my entire prescription benefit for the year was used up for ONE month's handout, plus I had a $200 copay when I was told it was free (I told the discharge nurse these brand name antipsychotics were too costly, and she said no copay, but I was billed $200 later, and had to pay it)
The diagnosis was inconsistent with diagnosis of therapist and was based on false information from abusive spouse
they didn't set up where I was going of medication changes my regular out patient providers did
that made me worse than before I went in
I was very over medicated, against my instincts, and those instincts were correct once I got a second opinion. I was misdiagnosed with bipolar because I went manic on copious amounts of energy drinks- not because of a biological disorder. The drugs brought me down, but time/sleep during treatment would have done the same!
I only obtained a proper plan after a subsequent episode
I left when my own doc was appalled the treatment
Voluntary, private hospital, late 80s ( was 16), doubt I would have the same positive experience now.
I was already taking meds at the time.
Follow-up plan was poorly devised and seemed just to check boxes.
got out - tapered myself off all drugs - it took some time
One follow up told them was suicidal last I heard of them. Last attempt may of been successful. Hopefully yes but only time will tell and not going to the doctor to find out if I'm dying.
The Psychiatrist changed my perscirptions with disarterious results.
I was order to take oral and injection meds
I was asked to do an exit review but felt it would not be wise to honestly comment as i was worried i would be re-admitted at some point and they would have more ammunition against me.
Became an antipsychaitry activist
so my answer is irrelevant
Like whatever. Fix the damn system tired of losing friends to suicide. I love Billy btw. Loved your book too.
No one explained diagnosis.
I had no choice or options. I was violated.
They actually had me sign papers saying I was safe to leave the hospital when I told them I was no different if not worse ( signed papers with statement that I didn't agree but that I had seen the paper)
the drugs tranquilized for 14 hours straight when taken as prescribed; no information about tapering safely to a lower dose that I could function at was provided
followup prescribed inconsistent with their own diagnosis

What aspect of care was most helpful to you?

The medications1610.9%
The interactions I had with the psychiatrist117.5%
The interactions I had with the nurses42.7%
The interactions I had with other staff32%
The activities provided00%
The food00%
The physical environment42.7%
The interactions I had with other patients2517%
Group therapy and educational groups21.4%
The interactions I had with my family00%
The time I spent in a seclusion room21.4%
The time I spent in physical restraints00%
The opportunity to escape the stresses of my outside life (work, etc)2013.6%
Yoga, tai chi, massage, general healing00%
The coping skills I learned00%
Family visits64.1%
Support animals on the unit00%
Nothing at all was helpful3624.5%