Sandy

So, I've been taking a little break while ClinkShrink posts about the AAPL conference.  I always enjoy hearing about what she's learned there.  We both had the pleasure of being in the sky last weekend as we awaited the arrival of Hurricane Sandy, though my flight, the only one heading to the East coast from Milwaukee that was not cancelled,  did not include unscheduled stops in the wrong part of the country.  Clink and I were both pleased to get home, and even more pleased that our region was spared the brunt of the storm.  In 1999, a large tree fell on my house during Tropical Storm Floyd, and I've never liked storms since then.  If there's a post-traumatic tree disorder, I have it. 

So Seaside Height, New Jersey is a place I remember from my childhood.  The day I got my drivers' license, I drove two miles to a friend's house.  She and another friend jumped into the car and said, "Let's go to the beach."  Now I had been a licensed driver for six hours, and we didn't live near the beach.  "No," I said, "too far."  "Oh, come on."  Why not.  We drove to Seaside Heights, played games on the Boardwalk, and drove home.  No cell phones back then.  I dropped my friends off and returned home around 1:30 in the morning (no laws requiring midnight curfews back then, either).  I walked in and my mother greeted me with, "I was so worried, I thought you'd been caught in a flash flood."  Flash flood?  What flood? "It rained," I said.  She stopped and said, "Where were you?"  Ah, obviously someplace where it hadn't rained.  I like that memory and I don't like seeing photos of the rides in the water.  

To all those who are still feeling the effects of the storm, our hearts go out to you.

Thinking About Bellevue

Little did I know as I was writing that last post on Sunday that just a few days later some of the same docs I was listening to and learning from would end up evacuating their hospital. When I read about the desperate conditions at Bellevue Hospital in New York as the storm struck and the remarkable efforts to evacuate every one of those hundreds of patients---without any loss of life, to my knowledge---I was impressed and humbled.

Every hospital and institution theoretically is supposed to have emergency policies and procedures, and is supposed to run occasional disaster drills to make sure everyone is aware of them, but who ever really believes they'll be needed or used? Those kind of large scale, potential mass casualty events seem to horrible to think about or really imagine could happen. Until they do.

There's not much I can do from a distance, but from my brief contacts with the Bellevue docs I know that those seriously mentally ill patients and prisoners received the best care possible under the worst possible conditions.

Let's hope that when the storm clouds clear and the rubble is swept away, the hospital that re-emerges is a newer, better and brighter one. The patients and staff deserve it.
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Addendum from Dinah: there is an article on the Bellevue evacuation here. 

The Psychology of Survival

I read this BBC story recently about the Chilean miners trapped for 17 days, who now face months of waiting underground while a rescue tunnel is dug. Although they are all physically well and expected to survive, they face the psychological challenge of waiting for rescue from the cave.

This story resonated with me because lately I've been hearing a lot about a new book, No Way Down, which was featured on NPR along with some other mountain disaster books. No Way Down covered the story of several teams of mountain climbers who were stranded on K2 when an icefall cut their ropes. Most of the climbers died although a few managed to pick their way back to base camp.

Survival stories have always been popular. Entire television series now feature teams of people pitted against one another to overcome some test or challenge. Disaster movies were popular back in the '70s, when the Towering Inferno, Airport and the Poseidon Adventure let us watch people get picked off one by one.

Why do we love this stuff?

I think it's because these stories reflect humanity's greatest strength, the power of adaptation. Whether we're talking about natural disasters, accidents, the exploration of Colonial American wilderness or longterm science expeditions to Antarctica, the psychology of survival is fascinating because we like the idea that one's mental attitude can make the difference between life or death.

A search of Amazon reveals a surprising number of books about survivor psychology. Most focus on outdoor adventurers, but others were based on interviews with survivors of accidents like plane crashes or fires.

The survivors in these books lived because they were trained and experienced in outdoor living. They weren't "survivalists" per se, people who stockpiled food and weapons for the future fall of civilization. These survivors were people who were able to stay calm and reason in the face of fear, people who retained their optimism and determination in spite of great odds. Survivors focussed on others rather than themselves, either thinking about their families or their fellow survivors.

Sitting in a prison cell for several years seems like nothing compared to surviving a high altitude mountain disaster, but I think there are some principles that apply in both cases. The prisoners who do well are the ones who are future-oriented and determined to "work the time" for self-improvement. They have external family they care about and plan to return to. And yes, previous prison experience helps too.

Variations in Response to Stress-- from the NYTimes.

In "Down and Out-- or Up" New York Times write Benedict Carey (he likes to write about psych stuff) discusses suicide, psychological distress, and resilience in the face of the crashing economy. Carey writes:
----- Just as loss itself comes in different flavors, from the bittersweetness of divorce to the acid tang of public condemnation, so too do people’s responses to loss differ, sometimes wildly. There are people who fall hard and do not find their feet for a long time, if ever — a condition some psychiatrists call complicated grief. And the depth of this economic collapse has unceremoniously stripped thousands of far more than money: reputations have reversed; friendships have turned sour; families have fractured.
------
I agree-- some people grieve and move on quickly, others never go back to who they once were (even with therapy and anti-depressants). I wouldn't have put it, though, that they do not find their feet, I would have said they find different feet. They become a little of someone else, often someone who isn't quite so motivated to work or travel or run in the rat race as the person they were before, but someone who might eventually find a new and quieter life. It is as if their values and goals change. Sometimes, it seems, that's just the way it is.

Carey goes on to write:

--- In any group of people, moreover, there will be a handful who are exceptional, who find some release or hidden opportunity in a seemingly devastating loss — a kind of Zorba response. In one study in England, psychologists found a bricklayer who, after being paralyzed, became an academic and now says the injury was the best thing that ever happened to him. Other research has recorded significant improvements in the lives of some people after they lose a loved one.
---

I'll end with that. Oh, but in case you missed it, the Ravens won.

But I Do Want To Talk

First, Roy wants your opinion about Online Access to Prescription History, so if you haven't chimed in, please do.

This post was inspired by ClinkShrink's post, I Don't Want To Talk, where she discusses mandated debriefing after trauma and what role that might have in either preventing or causing mental illness (Roy: which is what we spent all of podcast #46 talking about).

Disaster Psychiatry is a field that it still defining itself. It's a close-to-home issue for me because Shrink Rap was started as a way for me to deal with some residual angst I had after returning from a couple of weeks in Louisiana where I worked on the Katrina Assistance Project. Roy & Clink got sucked in, but what can I say? At that time, I wrote a piece about my experiences and posted on it's own blog link. I talked a bit about the stuff ClinkShrink discusses-- some history of the Mitchell Model of Critical Incident Stress Debriefing, as well as Sally Satel's paper on how the mental health industry exploited the terrorist attacks of September 11th. You can click HERE to link to my Katrina Reflections.

Since ClinkShrink wants to talk about mandatory debriefing and whether talking about a trauma lessens it's impact and prevents the development of future psychopathology, I'll talk about my own thoughts about the role of psychiatry in the aftermath of a community trauma.You can define community in a big or small way, but I mean a shared experience as opposed to a traumatic act to a single individual .

There are five concerns from a shrink's point of view. There may be more, but these are my random thoughts and it's our blog. Do chime in on the comment section.

• There are people with psychiatric disorders who may no longer have access to treatment-- perhaps because they need to relocate, because their doctor &/or records have been obliterated, their pharmacy closed down-- and they are at risk for a relapse of a pre-existing illness.
  
• There are people who develop psychiatric disorders as a direct result of stress-- it's not unheard of for people to become manic after the death of a relative, to become anxious or depressed, and so if psychiatric symptoms are precipitated without disasters, it's safe to assume they can be precipitated by trauma. Certainly, some of these people may have underlying disorders that would eventually be unmasked anyway.
• There are people who develop psychiatric disorders as a direct result of the specific trauma who may not have ever required the services of the mental health profession if such an event didn't occur. The question here, and the one that ClinkShrink addressed, is whether early interventions to the entire population alter the likelihood that someone will develop a psychiatric illness. Who to target, what to target them with, and if it will matter are all questions to address
  
• There are people who are distressed by an objectively distressing event but who don't (and hopefully won't) develop a psychiatric condition. These people often feel a need to talk and are well-served by friends, family, and religious leaders. The role for psychiatrists here is one that should be taken only if the trauma victim identifies himself as a patient and requests treatment. There seems to be a statement in our society that it's bad to not talk about troubling things-- this is true for some people who feel a need to talk, but it's a blanket statement that often crosses the line into being judgmental.
• Lastly, there is question as to the role mental health professionals should take with disaster workers who go to the aid of the victims. We're back to the Critical Incident Stress Debriefing and I wonder if the issues are different for those who are in the position of being helpers voluntarily (Red Cross workers and assorted humanitarians) versus those who go as a job requirement-- fire fighters and the like. I'm not sure what to say here. Again, this speaks to the issue of interventions to prevent the development of disorder in a population that might remain healthy without intervention.

Ugh, I can't get a picture in. Open all those alligator mouths and yap it up for me.

Two Years Later

It's quiet here at Shrink Rap. I've been watching the sidebar poll on sleep meds (trazodone is winning) and ClinkShrink came over to eat pizza and hand out candy yesterday. I think I graced the trick-or-treaters with a "one for you, one for me" technique that left me with a very pleasant chocolate buzz. Roy is under the floorboards, or so I've been told. He'll come out soon, I imagine, to a burst of posts and I can't wait to hear how our podcast sounds with all the new equipment.

So two years ago at this time, I headed off to Baton Rouge as part of SAMHSA's Katrina Assistance Project. I spent two weeks there in what was a moving experience (read about it here), but somehow it seems so very long ago. So long ago, that I forgot about it until I was surfing this evening and came across a piece on KansasCity.com about storm victims who still live in FEMA trailers and how the rate of suicide attempts among trailer occupants is 79 times the national average. 79 times. Old news, I suppose, as it was reported in the Spring in the Annals of Emergency Medicine (not on my hit list) and Alix Spiegel, who's done a number of NPR pieces on Mental Health issues in Katrina victims, did a story on this back in August. See the the NPR story here. Coming across the KansasCity.com story, complete with photos of a trailer park, was a jarring reminder to me what was. Ancient history to me, but I sat in those trailers, talked to those storm victims, wondered if I was helping, believed then that their lives would get better. For all I know, all those people are in the same place, in the same trailers, struggling the same struggles, though I imagine when two months have turned into two years, the element of Hope gets lost. The rates of depression are apparently seven times the national average, and 79 times the rate of suicide attempts is hard to imagine. For me, I'm suddenly and unexpectedly revisiting images, feelings, people, that I hadn't planned on thinking about tonight.

Katrina Assistance Project

In November, I spent two weeks working in Louisiana as part of SAMHSA's Katrina Assistance Project. I wrote about my experiences in an essay I will link to here:
http://shrinkrap2.blogspot.com/" >Reflections of a Katrina Psychiatrist