Saturday, May 28, 2011

Guest Blogger Dr. Jesse Hellman: More Thoughts On Rachel Aviv's Article on Involuntary Treatment


Jesse has wanted to do a guest blog post for a while now, and The New Yorker article finally got him blogging. I wrote a brief post yesterday, but he does a more thoughtful analysis of this complicated and provocative issue. Clink is off somewhere.. I am looking forward to hearing her thoughts after the holiday.
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In “God Knows Where I Am” Rachel Aviv sees the protagonist Linda’s
refusal of treatment as an expression of her illness. The moral
impasse she describes for our profession, though, is real: denial of
the need for treatment, or of one’s illness, can be an expression of
that illness; the refusal of treatment can also be a valid position
which we understand and support.

Mental functioning can be variable, at times better and at times
worse. At times the craziest thoughts are held in check, or do not
manifest themselves, while at others they hold total sway. The
underlying assumptions of our society are shared by us, and these
shape our reaction to the illness that Linda has. Other societies,
with different traditions and philosophical underpinnings, are
comfortable with very different stances.

Before Linda was discharged from the hospital the staff did everything
they could to dissuade her, and to provide for her safety. She
rejected every effort to provide housing and support. The hospital
argued that she was too sick to make decisions which even included not
allowing the staff to notify her sister and daughter. After her death
the family sued, stating that insufficient effort had been made to
protect her. The hospital then argued she was not sick enough to
justify stronger measures. What was true?

When we look at a complex issue, or event, we naturally can only see a
part, and our response is shaped both by what we see as well as the
assumptions we carry. What weight to we place on independence versus
the rights of others? What extrapolation can we make to an unusual
thought, in that do we see it as the harbinger of insanity or of
artistic creativity? Do we value religious musings or find them
suspect?

Aviv lets us see that while a part of Linda’s functioning might have
been creative, artistic, perceptive and so on, it was increasingly
shaped by an imagination which was not tempered by reality. It was as
if she was in a dream but could not awake, a dream which increasingly
dominated the most important parts of her ability to survive.

So what is the proper role of society when confronted by such illness?
What if her fantasies had shifted from thinking spies were all around
her to imagining the world could only be saved if she were to shoot
her congresswoman?

83 comments:

Rob Lindeman said...

Even if one posits that all murderers are insane, it does not follow that all insane people are murderers. In a free society, unless and until an individual commits a crime, we cannot, MUST NOT, incarcerate him involuntarily.

As I commented in an earlier post: psychiatrists ought not insist they can tell if a person is dangerous to himself or others; and psychiatrists ought not insist that murder and suicide can be prevented. To suggest otherwise is itself dangerous nonsense.

You will counter that the courts will come after you if you don't make determinations of dangerousness. Please stop blaming the courts, people! If you must protect yourself with "careful" documentation, do so, but please take responsibility for your OWN actions! Those actions result in innocent people being jailed without committing crimes!

Anonymous said...

When society starts locking up the patient with diabetes who refuses to lose weight, stick to the diet the doctor ordered etc depsite being told he/she will lose legs to gangrene and then die, I will agree that society should lock up every person with a psych diagnosis deemed a danger to themselves. A danger to others brings up different issues. The first person with diabetes, is killing him/herself. Is that so different from this woman starving after running out of apples. She was diagnosed with a mental illness. She refused treatemnt. Her family is upset. Every family is upset when they think the hospital could have done more--no matter what the illness. This woman found peace. She was not stupid. If she wanted outside help or more apples as the barrel ran low, she would have known what to do just as the individual with diabetes can say no Doc, I like my sugar and I will eat it and just as a patient has the right to refuse treatment for other diseases even if that offends some sensibilites. People with cancer get to decide if they want chemo or not. Nobody calls them crazy if they say no. Enough.Insight, inshmight. People have rights.

Roy said...

Is this a black and white thing, or is it more gray, and the disagreement is about where to draw the line?

So let's take a different scenario. An elderly woman with severe dementia and no family insists on leaving a nursing home, despite her inability to dress properly for the 20 degree F weather outside. Should her right to self-determination be honored? Even if this meant likely death?

Rob Lindeman said...

The answer to Roy's question is "yes". Either this woman owns her own life or she doesn't. I say she does. The state doesn't own it, and neither does God. The ultimate freedom, so to speak, is the freedom to check out when you choose to.

Anonymous said...

Rob Lindeman writes,"In a free society, unless and until an individual commits a crime, we cannot, MUST NOT, incarcerate him involuntarily."

I agree with that statement. I think with freedom comes responsibility. If people are breaking laws then they have to expect some loss of freedom. So, when she was driving under the influence or breaking into someone's home you get no argument from me that she should be detained.

But for those who have committed no crime, I think very differently. I have not ever committed a crime (unless you count two traffic tickets for speeding). I think those who have committed no crime (with the exception of someone who isn't oriented X 3) should have the right to say, enough, leave me alone, go away. I saw inpatient how easily patients' rights can be violated. I do not recommend doing what I did which is telling a psychiatrist they are making everything worse, particularly when it's the truth. Because then your incarceration very quickly becomes about the fact that the psychiatrist is pissed off. As he stomped out of the room that day, I realized very quickly what I had to do. I was going to have to kiss his butt or find an attorney in order to get out.

Although I had not driven myself there which they knew, they made no effort to see if I had a way home. They didn't care about my safety, because if they had I wouldn't have had to walk alone in a scary part of town and including walking across a freeway to get home. They actually put me in harm's way.

So, in a matter of 24 hours I went from being supposedly so ill that I needed to be forcibly stripped and put into a cage, to being dumped out on the street with no way to get home. It's ludicrous to think that doing that will save lives.

Leslie

Anonymous said...

COME PEOPLE! HEAR ME RAW! KNEEL DOWN BEFORE ME! FOR I AM THE TRUTH! LOL!

Imagine being in a worship service where the pastor pointed to a member who had just given a large gift and told him that Satan filled his heart? And then watching as the man dropped dead. But that’s not all, a short while later the man’s wife enters the church and drops dead as well! Would fear fill your heart? Would you commit right then that you, 'Will never lie again'? This message from Acts 5 teaches that God loves His church enough to discipline it to keep it pure and growing.

you are GOD DARN UNBELIEVABLE! LMFAO.

Bec said...

I know of quite a few people who have been floridly manic and involuntarily detained against their will. They hated it. But once they had stabilised they were appreciative. It stopped them from doing things they would later regret; spending all their money on shopping sprees, quitting their job and driving across the country and any number of other things people do while they are manic.

Personally, and in my current stabilised state (I have bipolar) I believe that if I am ever in that situation I would hope that someone would detain me until I'd stabilised. I may not like it at the time, but I personally believe that it would be in my best interest.

I agree with Roy that it is a grey area. Maybe it is something psychiatrists could discuss with their patients when they are stable. I don't know. It can be a very touchy issue.

Dinah said...

So the consensus so far seems to be that things ultimately played out for the Linda Bishop as they should have.

I don't imagine there is any psychiatrist who read this story and said, oh yes, obviously this woman with a psychotic disorder belonged in jail for a year and a half awaiting a competency determination. I was appalled, the "system" clearly doesn't work.

Beyond that it does sound like the system (and I'm not commenting on the time frame) worked as intended-- the patient was found competent to be her own guardian in a hearing, the factors were considered, there was no more treatment to be offered to someone who was not imminently dangerous, and she was released, on her own terms, to live as she wanted.

These are really difficult issues. Leslie's story is also horrifying...there are clearly bad psychiatrists out there, and awful facilities, and bad things that happen that could have been handled better. Maybe the issue should be more to fix the wrongs than to throw out the entire field of psychiatry?

What makes Aviv's story remarkable is that the patient refused treatment in the hospital, and that her outcome was horrible, tragic, and extreme (in psychiatry, death is not an expected outcome).

A more usual story is that a patient becomes sick, then dangerous (If they are actively violent, can we we then determine that they are dangerous?). They enter the hospital, voluntarily or otherwise, they take medications (many patients who are committed involuntarily do agree to take meds). They get better, sometimes within days. Better, they are either permitted to sign out AMA (because they are no longer deemed dangerous and are therefore no longer certifiable) or they are discharged (hopefully with a family member arriving to give them a ride home?), they go home, and at some point stop their medications and the cycle starts again.

When I was a resident, there was a patient on my unit who would stop her meds, smoke a little marijuana, get psychotic, and heard voices telling her to kill children. When she was on the porch with a knife, family brought her to the hospital (no protest) where she was voluntarily admitted, voluntarily took meds, and left in a week or so. This happened 10 times...no clue how the story ended, I was only in it for one few-day blip. I guess it doesn't fit here because she was a voluntary patient.

You all are selling me on the idea that there should be psychiatric advanced directives. As much as you don't want to be treated involuntarily, there may be someone out there who says "Hey, please don't leave me sick, treat me" and they should have that right.

I'm very uncomfortable with forcing people to do what they don't want to do....even when it was just cajoling people to let me get a blood gas or draw labs when I was an intern (funny how many people were medically ill in the hospital who had no mental health issues who would give the doc a really hard time about getting tests.).
But this is why I do outpatient work in a setting where my patients are all voluntary.

Okay, I'm ranting. Just watched Salt. It was pretty good. And Rob, psychiatrists don't generally believe that we're all that good at predicting violence. We hope our treatments avert suicide, and patients sometimes tell us that treatment saved their lives, but statistically we're well aware that these are anecdotes and the statistics remain unclear. Isn't it that way in all of medicine? I remember when cholesterol-lowering medications were found to be associated with higher numbers of violent deaths.

Sarebear said...

My answer to Roy's question is No. She shouldn't be allowed to choose to leave in that case, because she's not mentally competent to make that choice. 5 minutes after leaving she could wander into the street in front of a car and die; would those saying yes let her go then say that she chose death? Whether it be from cold, or a car? She can't CHOOSE anything when her judgement is so impaired as to make her incapable of discerning safe vs. unsafe. She is a DANGER to HERSELF in this situation, as well as potentially a danger to others (what if the person in the car that hits her isn't wearing a seatbelt, or has some other injury from trying to swerve to avoid her. . . )

Oh and I answered YES on the new poll, because much as I might hate it at the time, even fight tooth and nail potentially, I would want me to be treated for the sake of my family and to become stable again (wait, so why did I refuse hospitalization two months ago when the psychologist strongly suggested it . . . like I say I may fight it hard). I'm not waiting for someone to force me, though. I don't WANT that but I recognize that there may come up situation(s) that may make that the best option for my health and for the sake of my family too.

Anonymous said...

I listened to the podcast of the author and was so glad she mentioned this point at the end:

The place that rejected Linda for housing because she refused to consider herself mentally ill, needs to rethink that position. Perhaps if that hadn't been a requirement, there would have been a totally different outcome.

In my opinion, it accomplishes nothing to force someone to admit they are mentally ill. Don't professionals realize how humiliating that can be for folks?

Unfortunately, many of them are so stuck on issues of power, that they forget it is about helping the patient and not about their issues.

Obviously, it is a complicated picture but I am very angry that this might have indirectly led to someone's death.

AA

Rob Lindeman said...

The ends do not justify the means. If a person is committed involuntarily, is given a drug, and later appreciates his incarceration, nevertheless a crime against this person's civil liberties has been committed.

Put another way, a person's attitude toward his own treatment by the State is irrelevant. The next person they come after may not (and judging from the evidence often DOES not) have the same attitude. Civil liberties are yours whether you want them or not. Just because Sigmund doesn't want them doesn't give the State the right to take them away from Carl.

Anonymous said...

Having been treated against my will, here are some thoughts. The current system does not really provide treatment. It locks a person away until they are either deemed no longer a danger to themselves or the bed is needed for someone more in danger. The truth is that many suicides take place in the days and weeks and months AFTER someone has been locked up and then discharged. There are probably too many reasons to list but some possibitilies include the lack of treatment in the community, the fact that many, many patients one somewhat stabilized on drugs in hopsital are able to get out by saying they are no longer considering suicide. They can say it in a calm, even tone, the doc discharges and off they go to shoot themselves because the drugs very often "normalize" behaviors but do not make a person feel better. Many times people know that in time they will end up back in the "care' of some hospital and they choose death over a lifetime of the revolvign door. So if I were to experience another episode of serious mental illness I would only want to be "treated" under certain circumstances. I would want treatment to look a lot different than the current traumatizing hospital experience. I would want humane treatment from staff. Some are not so bad but too many are bullies and can get away with it. i would want to feel safe instead of unsafe in the place i was being treated. I would not want to be given more drugs if I said that my eye or stomach hurt. Yes, if you have a physical complaint they will chalk it up to your "illness" and try to cure your migraine with more Risperidal. That was my experience, or one of them. I would want the entire mental health system revamped. They revamped many mat wards so that childbirth and all the associated medical procedures are more homelike and comforting. Does anyone really think psych patients get better in jail cells or in rooms that are airless cells where they get interrogated rather than spoken to or with? If the system cared about human beings or as set up to deal with people as human beings , more might be willing to accept 'treatment". I am not anti psychiatry but huge chages are needed in how society treats people who need to be treated. And in the end, if all those changes and more were made, and a person still refuses, let them go. We let people skydive. We let elderly and not so elderly cancer patients decide to terminate treatment, knowing it means they will die sooner. If they had better quality of life on chemotherapy, many would not terminate treatment. if the woman with dememtia in your example felt safe she would not be out running around and freezing. For the woman in the article, running out of apples was the best thing that could have happened to her. We are not criminals. psychiatrists do not really seem to understand that not everyone wants to live, at least not so long as the treatemnt is about as bad if not worse than the illness.
I have heard psychs and psych nurses speak of how they ares stigmatized by association. perhaps if they worked in places that treated people as people ought to be treated just because they are people, some of the stigma would lessen. At this time much treatment is not much different from being locked up for a crime and also given drugs. Time for a big shakeup. I know it won't happen.

jesse said...

AA hits the nail on the head. Rachel Aviv does not explain why there was a requirement that Linda acknowledge she was mentally ill in order to get into the housing. This was not a requirement of the professionals, but likely a requirement of the housing bureaucracy (possibly tied to liability questions, or funding)? Often it appears as if the professionals are responsible for a particular thing when in fact they have no ability to do otherwise. The issue about insight being a requirement for the housing is essentially the tragic turning-point of this story.

In this instance the system worked, but the patient died.

In Maryland a person can be held for treatment involuntarily only if he is shown to be an imminent danger to himself or others. This is not decided by the psychiatrist, but by an administrative law judge in a hearing in which the patient is represented by counsel. The standard of proof is "beyond a reasonable doubt" as in criminal cases, not the "preponderance of the evidence" as in civil ones. And the patient must be shown to be dangerous in the hospital. Dangerousness outside of the hospital is not admissible.

Roy said...

Clarification on Jesse's statement. An element of dangerousness OUTSIDE the hospital can be used for involuntary HOSPITALIZATION in Maryland. Dangerousness INSIDE the hospital must be shown for involuntary MEDICATION (since the Kelly case).

Dinah said...

I didn't read this as the patient had to sign off on "Yes, I'm mentally ill." Typically, housing for people with mental illnesses is administered by agencies, and funded as such. There is a requirement that people who are placed in these homes must have a mental illness, and perhaps somewhere on the form it noted this.
I'm not sure it is a given that if this wasn't on the form, she would have signed in---remember this is someone who drank and drove and crashed a car to prove that the police were wrong (wrong about what?) As always, we have part of the story. Perhaps she just didn't want to be in housing for those deemed mentally ill? It likely came with certain requirements, perhaps agreements about who can visit, maybe even hours, or requirements to be in treatment. I don't know. At the same time, I don't know that it's possible to designate funds to house those will mental illnesses if that housing isn't restricted to those with mental illness.
What happens if patients sign the form, but cross out the line that says something about having a mental illness and initials it?
We thrust all sorts of forms at people (and I get them thrust at me: I don't do HIPPA sign off forms).
This is a funny catch 22.
And she may have well been happier and better off in the farm house, reading, watching nature, until the end. Dying of a slow miserable starvation sounds horrifying, and I do wonder (and I don't KNOW) if a brief encounter with another human being might have made a difference and given her another 35 years of life.

Rob Lindeman said...

I thought judges make determinations of dangerousness only on the basis of testimony (written or otherwise)by one or more psychiatrist. Please correct me if I am wrong

kw said...

It's an impossible question/poll because the variables are so wide-ranging. Questions of what defines a severe episode are huge. Violence to others? To self? Inability to care for oneself? To function? To earn money?

Another huge variable that is not taken into account is the viability of the proposed treatment. The fact of the matter is that inpatient treatment is not across the board excellent. It depends on the facility and oftentimes, even on the individual physician.

I am a highly successful professional with a healthy, happy personal life and bipolar 1 that is generally but not completely controlled with medication. I've been involuntarily hospitalized three times for florid mania/psychosis. Twice, I quickly responded to appropriate medication. The third time, I was assigned to an arrogant psychiatrist who worked on his own agenda, contrary to my records, family requests, etc. Let me state that this physician is the head of a inpatient unit of a major ivy league university hospital center. I forcibly received "treatment" that was clearly counter-indicated and made me unquestionably worse. The abuse and humiliation I suffered at his hands was enormous, yet "justifiable" according to his falsified records. Ultimately, only the involvement of an attorney released me from him and into another hospital altogether. Within 4 days in the second hospital, my symptoms began to resolve -- as they always had in the past. Simple. Clear cut. Unfortunately, I had lost three weeks of my life to his ministrations. The "treatment" I received from him was so detrimental and damaging on a medical level, not to mention humiliating that I would now waver over whether or not to answer "yes" or "no" to your poll. Though it would destroy my wife and kids, I quite frankly have to say that if there was a high likelihood that involuntary treatment would include treatment by this man or someone similar, I would choose no....even knowing full well that I would likely die, instead.

I see a strong argument for psychiatric advanced directives. I have one in place, though it's not clear to me if they are always binding. Particularly for well-esteemed psychiatrists with unlimited power, tremendous egos, and the all-too-easy justification that the patient is too crazy to know the difference.

You are not gods. You don't know everything. Unfortunately, choosing "yes" in this poll cedes you god-like powers that you do not always wield wisely. So how, then, in good faith can I give you blanket ability to potentially do so much more harm?

jesse said...

kw, that is a powerful story.

One of the problems is that our field, like so many things in life, has so many variables it is impossible to craft rules that cover everything ideally. There will, unfortunately, always be stories like yours, or Linda's. The abilities that allow one to become chairman of an important department (or company, or country...) may be counter to those that make one the best practitioner.

The problem, I think, is this: How can we be certain that important decisions involving us and our families are made only by professionals who are competant, compassionate, and wise?

Rob Lindeman said...

Here's an idea: instead of relying on professionals, (competent, wise or other-wise) why don't we make important decisions regarding our lives OURSELVES?

And please answer the question regarding psychiatrist involvement in civil commitment. I suspect you are ducking. Perhaps Maryland is different from Massachusetts, but here, your application has to be signed by a psychiatrist

Sunny CA said...

Many of the comments mirror my experiences. I was abused and mistreated as an inpatient and if I had the option I would refuse in-patient treatment in the future. Too many people who work on psychiatric wards and as aides in nursing homes, seem to hate working there and hate the patients therefore abuse the patients as a result. I would also prefer as a senile geriatric to die in a snowbank than be abused in a nursing home. At 18-19 years old I worked in a nursing home and occasionally turned a corner or glanced in a door to witness physical and emotional abuse of senile geriatric patients.
Thanks, Rob Lindeman for being on the side of the involuntarily committed. I vowed as an in-patient that once out, I would fight for the rights of the in-voluntarily committed. I haven't done it. I don't even know where to begin fighting that fight. I have not even spoken out in a public forum because I am afraid to let my mental health history become public. I hope someday I do something to help.

Anonymous said...

It is truly a complex issue without a black or whit response. Don't we already hold hundreds of thousands of mentally ill individuals against their will through the prison system? Individuals who, in another era, would have been in state hospitals? As a highly functioning professional with severe depression and complex PTSD, I think advance directives are critical. I honestly don't always know if I'm a danger to myself, and I appreciate the active partnership with my partner and my psychiatrist.

Sarebear said...

There are always going to be many unpleasant, demeaning, horrible inpatient stories out there.

I do not say this to diminish the experiences of those who have been mistreated, abused, punished, etcetera.

I say it because sometimes on posts like these and comment threads like these, the unpleasant experiences tend to overwhelm some of the intention of the original post, not that the relation of these unpleasant experiences is necessarily off-topic. It's just that people who have been satisfied with their in-patient care, I don't think have near as much motivation to speak up about it, as those who have been wronged.

As a caveat, here, I must say I've never been in-patient; I've only been in the ER for a suicide attempt, stomach pumped, assessed by people, etc.

Obviously the abuses and problems in the system need fixed, and even when these are addressed, there will always be imperfect people, arrogant people, etc. in any system . . . which does make me afraid to perhaps be subjected to someone like that ivy-league guy kw mentions.

That hasn't been my primary reason for rejecting hospitalization though. Neither has fear of abuses, although I worry about that. Plain and simple, it's my terror of being trapped. I suppose they'd be able to treat this terror in there but I have no experience.

Anyway, I just thought I'd poke up with a few thoughts, esp. since positive experience people may not have much incentive to speak, with no strong motivation to overcome possible embarrasment at being hospitalized, like the strong motivation to speak about abuses that the wronged have.

Anonymous said...

I suppose starving a rough way to go but we allow hunger strikes. We allow people to smoke 3 packs a day and gee cancer is a rough way to go, too. We allow people to kill themselves everyday so long as they are not "crazy".

Dinah said...

kw: The poll is for "fun" ...it's not going to be used for anything, it's just because people are talking about the topic. It's meant in a general way, so while I checked that if I was severely ill, I'd want to be treated against my will-at-that-moment, I actually would not want to be treated by the psychiatrist you saw or in the facility that treated Leslie. It's a quicky question, not with every caveat. I think I assumed reasonable care (and I'm well aware you don't get to call the shots in those settings), and that when I returned to being well that I would then be able to reassess and choose to terminate the treatment.

Rob: I've never been to a civil committment, I'm leaving your questions to ClinkShrink and she's away for the holiday.

I'm not really certain that I follow the concept that people should never have treatments inflicted on them against their will: this happens all the time. If you get hospitalized with diabetic ketoacidosis, they control your diet, they forbid your family from bringing in twinkies. You may feel it's your right to smoke, but I don't suggest you do that in the ICU with your oxygen running--- or should you have the right to blow up the whole unit? You don't get to decide that you don't want to wear a seat belt, or in some states, they make you wear a bike/motorcycle helmet, even if you don't want to. In the midst of labor, if you scream for pain meds, maybe you'll get them, but if there's no anesthesiologist on site, or you're beyond a certain point in labor, or maybe they are containdicated or will kill your baby, then you don't. And you can tell your pediatrician that his vaccines will give your child autism, but the schools may still insist your child get them.
Even without a mental illness, they don't just let you check out when you choose if you have a life-threatening condition, or a condition that may hurt someone else: first they call a psych consult and begin a series of legal maneuvers. And even if you are found to be mentally healthy, I don't think you get to leave if you tell them your plan is to go cough TB germs on every person you see on the street.

Anonymous said...

Dinah:
I know that I can stop any treatemnt anytime for any physical illness i may have and while the doc will not be pleased, I will not be locked up even if refusal to adhere to a drug regimen means I will die sooner. Diabetic people are not locked up under a special act and they can discharge themselves against doctor's orders. That is their right. If you or your family member signs a waiver, you can get yourself of a family member dsicharged against doctor's orders for just about anything. If someone chooses not to show up for dialysis, are the cops going to come to escort them because they are endangering their life? Not likely. People with psych diagnosis get locked up for almost nothing. if they look sweaty they will say lock them up, they are having an episode. Never mind the heat wave or that everyone else is sweating.
And it is easy to tell a doc hell no I don't plan to do anything and then go do it. The system is awful. It doesn't save lives. it doesn't help sick people. It helps people who find other peoples' thoughts disturbing.

Rob Lindeman said...

Oh my dear Dinah, anon beat me to it, but I must add: what a mass of category confusions you have committed! For starters, your premise, that we treat people against their will all the time, is wrong. Even if the were true, it would justify nothing. Tu Quoque (roughly translated: "so's your old man!") is a hell of a bad argument.

So many of your examples have nothing to do with treatment by physicians of patients! I will let anon's answers speak for themselves. TB is a communicable disease. Insanity is not (no jokes please)

I will add, as a pediatrician, that many of my families choose not to vaccinate their children fully or at all. Here in the cradle of liberty you can still get away with that. Perhaps the Therapeutic State is more firmly entrenched where you live.

Finally, I cannot stand any longer this "no-not-I", and "I've-never-been-to-a-commitment-hearing" dodge. Dinah, you know as well as I that the certificate of a psychiatrist is the sine qua non of a commitment proceedings, whether you've been to one or not (How is that, by the way? I'VE been to one, as a medical student!!!)

Anonymous said...

I am so afraid of involuntary treatment that I spent about 100 hours on my psychiatric advance directive. I also make sure the social workers in my county know me, and I have a worker at home, to advocate for me if I should become extremely ill again. I had my psychiatrist as one of my witneses for the advance directive, and make a note in my chart fot that day that there was no question about my competence.

I had too many abusive times inpatient to ever go back to the hospital. Most times it was ok, but a few times, there were a few extremely abusive bullying staff who enjoyed tormenting patients. I took careful notes while inpatient and got a copy of my medical records, THEN wrote complaint letters and met with the administrators of 2 of these facilities. I have been told in the years since that some significant changes were made. Both adminitrators said that nobody had ever complained before. One of my workers says that many of their clients are too afraid to complain for fear they will be committed.

I think psychiatric care is like end of life care - discuss this with your psychiatrist and therapist and all your family members so they know what you want and if you get them on your side, they will fight for what you want. This should be addressed early in the course of the mental illness. But you know, until it happened to me, I didn't know mental hospitals were often abusive. My first time was in a university hospital and everyone was wonderful.

Steve Daviss MD DFAPA said...

Good points, anon. I truly think psychiatric advanced directives are the way out of this mess, but only if they truly have teeth, cannot easily be countermanded due to "dangerousness," and provide liability protection when a doc follows said directive and it leads to a bad outcome. I am unaware of a single state where all three of these elements are in effect.

And Rob, I have to respectfully disagree. A certificate by a psychiatrist is not the sine qua non for civil commitment, at least in Maryland and in most states. The certificate must be by a physician; yes, even a pediatrician can do it. Or a psychologist (though, in Maryland, if one cert is a psychologist, the second one must be from a physician, but of any stripe).

Rob Lindeman said...

De jure (ie, according to section 12, the relevant statute in Mass) you're right. De facto, it is a psychiatrist who always signs the "pink paper".

Even though police are empowered via section 12, what happens in practice is that the policeman brings the accused crazy person to an ED, where they both wait, often several hours,for the psychiatrist to show up. My pediatrician colleagues direct parents to bring their kids to the ED where the same thing happens

jesse said...

Rob and various anons: Psychiatrists don't lock anyone up. It is society, not psychiatry, that says a person can be held if he is a danger to himself or others. The world is full of people who have psychoses and choose or don't choose to get treatment. It is only when they are an imminent threat to others or themselves, determined by a judge, that they can be kept in a hospital. The protections to the individual in the United States are so great that it is extremely difficult to get anyone treatment against his will.

Psychiatrists don't go out and find their patients. No knocks on a door: "you're psychotic, come with me." Others have intervened and brought the patient to an emergency room. Unfortunately many end up, as did Linda, in jail.

If a person with diabetes, or heart failure, or cancer starts attacking others the state will step in. If our thoughts do not result in a danger to others or an imminent danger to ourselves no one will bother us.

It took thousands of years for those with mental illness to be treated as human beings in need of care, treated by individuals who study how to help them. Perfect? No. But it is better than anything that existed before.

moviedoc said...

Rob: You're wrong. But Dinah is the expert on ducks. It depends on the state. In WA "Designated Mental Health Professionals" commit people. I'm not certain, but I believe a judge only gets involved later. When I was still in NY, before '86, a single physician, not even sure it had to be a psychiatrist, could commit for 72 hrs, but it took 2 to extend it, and I did testify at a few of those hearings before a judge. Here in WA it is very nice not to have to commit people. Physicians should diagnose and treat, and if society wants to deprive someone of their civil liberties based on some mythical crystal balling about dangerousness, don't involve me.

Anonymous said...

Dr.Davis, I agree with your points on the psych advance directive. I have also heard that they can be pretty much worthless and overruled, so that needs to change. I fully support removing the liability for physicians as well.

For the me, the line is if someone is infringing on other peoples' rights - like the mother waving around a knife at her kids. That's child abuse, and no one has the right to expect freedom under those circumstances. What's the saying, "You're rights end where mine begin." My concern is mostly for people who are only a threat to themselves, they need to have the option to decline all services.

In Texas, some psychiatrists play around with informed consent. They will threaten patients into signing in as a "voluntary" patient. How threatening someone to sign a document could ever be considered a "voluntary" admission is beyond me. It's bs, but it happens.

Leslie

Anonymous said...

I meant "Your rights..." not you're. I need a nap.

Leslie

Roy said...

In most ERs in our state, it is two ED physicians signing the certificates. In the few ERs who hire psychiatrists, it is one psychiatrist and one ED doc. In my hospital, 99% of certs are by the ED docs. De jure and de facto.

Rob, have you ever treated a child against his or her will? Parent says treat and child says no. If so, what was your rationale?

Anonymous said...

This topic is extremely close to home for me. My mother inlaw believes she is depressed and suffering PTSD and believes that she is managing her conditions without medical help but from our perspective she seems very ill, very paranoid, and living a highly impoverished life - she has disconnected her water and electricity, eats only food that she has "gathered" from the neighbourhood. She has knocked her teeth out because she believed that the dentist poisoned her. She is too thin. She has no insight into the paranoia which permeates her every interaction with people- needless to say she is very reclusive. Periodically she becomes suicidal but will never speak about it directly, we can only guess that is what is going on when she tries to give us her house as "early inheritance"...it's not good.

And yet, while we uneqivocably believe that she is unwell and her judgement is skewed by illness, we have not yet had the courage to force treatment on her. She is able to articulate very forcefully the ecological reasons for her spartan lifestyle and she always was a far-left activist so it is hard to say that these are not her wishes or that the logic of reduce, reuse, recycle is somehow an excessive response to climate change. She is very conscious of stigma - and always tells us stories of people she has seen talking to themselves etc as a way of telling us that she knows what crazy is and it aint her.

Ahh stress! I want her to feel safe and be healthy and warm and clean because, well, that's what I want for everyone. But I can see that she is making meaning out of the way she is living and I can see that forced intervention would be thoroughly traumatising and soul destroying for her. So we do the dance of care where we help her as much as we can without her realising. We encourage her to seek medical help for physical ailments (a recent deep cut on her leg for example) in the hope that someone in the medical setting will realise that she needs psychiatric care. She is not breaking the law so there is no chance of intervention coming from the legal apparatus.

We question everyday whether we are respecting her individuality or neglecting her basic needs. There is nothing easy about our situation and it sounds incredibly similar to the Aviv example. I pray our story doesn't end in the same way but I do not know whether we will be able to know when to draw the line and force intervention in order to save her life.

FL

Rob Lindeman said...

I do things to kids every day that they don't want done to them, including examining them. Here's the rationale: minor status is a fact based on a number (years of life). Minors, by definition, cannot give consent. [as an aside, if I happen to agree with the child contra his parents, I don't treat, but that's another matter]

Insanity, on the other hand, is a social assignment that has no objective basis (like age). Therefore if a so-called insane person refuses my ministrations, I have to back off. Please don't bring in dementia. We're talking about women like Linda Bishop.

Rob Lindeman said...

"Society" is a euphemism for the State. Jesse, psychotic people don't lock themselves up; society doesn't lock them up; the State locks them up, and they can do so only with the help of physicians. In Mass. at least, physician means psychiatrist.

I've learned so far that there's at least one state where physicians are not significantly responsible for incarcerating people guilty only of the crime of being crazy. That's enormously gratifying. We shouldn't be in the business of depriving others of their liberty.

This "no-not-I" business will not do. If you or your colleagues are involved significantly in taking away other people's liberty, please be honest enough to admit it.

Anonymous said...

Jesse: psychiatrists and other docs can lock people up on behalf of society. They are the agents of control. And a person can be locked up for several days, depending where one lives, until they are assessed and, in many cases, deemed not in need of treatment. Days, not hours.

jesse said...

Yes, physicians in an ER can have a person held up to 72 hours if they find him to be an imminent danger to himself or others, during which either he is no longer such a danger or an ALJ determines he is not.

Rob writes, "incarcerating people guilty only of the crime of being crazy." There is no crime in being "crazy." In the vast majority of instances we are talking about actions: cutting one's wrists, attempted hanging, overdoses, about to jump from a bridge, running naked through the streets, and many more.

A man I knew was arrested when, after creating a commotion in a store such that the police were called, he was found lying on his back in a busy street, talking to God. He was arrested and taken to jail, not to a hospital. Years later he was a homeless person, living in a park.

There is an assumption in some of the posts that expressed thoughts, of whatever nature, should be taken at face value. When people are observed to be a serious, imminent danger to themselves or others psychiatrists should not be called to assess them. Or, if they are, they should have no authority to have held for 72 hours those they find to be an imminent danger.

Granted that the system is not perfect, but just to whom would you have the police, families, and the public turn in such instances?

Anonymous said...

Things I've learned from my own experience:

1. Voluntary does not necessarily mean voluntary. Once you sign on the dotted line (which is sometimes done in Texas under threat or coercion) and the door clicks shut behind you, suddenly you are incompetent and if they want you to stay, you stay.

2. Don't be sad on Friday-Sun. There is no court in session on weekends (at least in Texas). You will sit there through the weekend whether you need to or not.

3. Be careful who you talk to. Make sure that the person you open up to has the same ideas you do about patient rights and autonomy. There are therapists out there, believe it or not, who will not flip out and try and have you hospitalized.

4. Good to have a family member who shares your opinion on involuntary treatment. I am lucky to have a sibling who shares my views.

5. Psych advance directives in Texas are worthless. Psychiatrists can disregard them in cases of emergency, which is when you would need an advance directive to begin with.

6. Know your rights.

7. Always good to have a friend who is an attorney and keep their number in your wallet.

8. If you find yourself inpatient and want out, kiss butt. It works. Disagreeing with the psychiatrist will be deemed a symptom of your illness, and they will try and keep you until you are all better (i.e. until you agree that this is helpful). Keep your thoughts on involuntary treatment to yourself.

9. Know that you're not alone.

10. Refer to # 6.

Leslie

moviedoc said...

When deciding whether to be voluntary or involuntary you should also know whether in your state involuntary commitment will affect your right to own or purchase a firearm or to have a concealed carry permit.

Roy said...

Why is it that some laws are ok (minors defined as under 18 by law cant make good decisions so can treat against their will for their own good as defined by another) while others are not (making treatment decisions for non-minors who lack capacity to make rational and reasonable decisions due to depression, psychosis, dementia, brain tumor, hypoglycemia, whatever the cause)?

I truly do not understand how someone would allow a vulnerable adult lacking decisional capacity to wander into the snow to die knowing her life could be saved. This seems to me to be a cruel and callous perspective. (Rob, I am not saying you are so, just that this perspective fells so to me.) I am trying to square this with my world view and just don't get it.

Anonymous said...

True, moviedoc. If they're going to put you in against your will anyway, best to sign in as voluntary for a whole host of reasons. An involuntary hospitalization can cause problems down the line with employment, etc.

Leslie

jesse said...

Many issues here!

DOCTOR:
Not so sick, my lord,
As she is troubled with thick-coming fancies,
That keep her from her rest.

MACBETH:
Cure her of that.
Canst thou not minister to a mind diseased,
Pluck from the memory a rooted sorrow,
Raze out the written troubles of the brain,
And with some sweet oblivious antidote
Cleanse the stuff'd bosom of that perilous stuff
Which weighs upon the heart?

DOCTOR:
Therein the patient
Must minister to himself.

Has nothing changed in 400 years? Do we now not even acknowledge that there is such a thing as a "diseased mind" bent on its own destruction? Is there no way to provide assistance without that mind's consent?

Rob Lindeman said...

Roy, as long as you continue to conflate childhood and dementia with schizophrenia, we don't have a common frame of reference to discuss this.

I have no problem with helping the ill and vulnerable. I do it for a living. I object to doing so via coercion, force, or fraud. It's not a difficult concept

Rob Lindeman said...

The doctor in Macbeth had it right. He had nothing to offer Lady Macbeth. Her affliction was moral, not medical. What we've "learned" in 400 years is to medicalize morals. That's progress? I don't think so.

Anonymous said...

I think Rob is right on the money. In fact, we don't have people who have dementia and are not oriented signing informed consent documents. Yet, we have people with schizophrenia sign informed consent documents which is saying they are competent to understand the risks, benefits, and alternatives to treatment. Then, people want to turn around and say the person with schizophrenia who was supposedly competent to sign in shouldn't be able to decide about whether to continue medications because they lack insight into their illness. You can't have it both ways. You are either competent or you're not. If you're competent when you agree with the psychiatrist, then you should also be considered competent when you disagree.

Leslie

Anonymous said...

Jesse wrote:"Yes, physicians in an ER can have a person held up to 72 hours if they find him to be an imminent danger to himself or others, during which either he is no longer such a danger or an ALJ determines he is not."

In real life, a person can be held even if there is no evidence that they are or may be a danger, intermittent or otherwise. A psych diagnosis is enough for some doctors to interpret ANYTHING they see from/in the bearer of the diagnosis as a need for assessment, in which case one can be held for up to 3 full days until a psychiatrist comes to say, no you do not need to be here at all. Guilty until proven innocent.

jesse said...

Rob wrote: "The doctor in Macbeth had it right. He had nothing to offer Lady Macbeth. Her affliction was moral, not medical. What we've "learned" in 400 years is to medicalize morals. That's progress? I don't think so."

Doctor: What is it she does now? Look, how she rubs her hands.

Gentlewoman: It is an accustom’d action with her, to seem thus washing her hands. I have known her continue in this a quarter of an hour.

Lady Macbeth: Yet here’s a spot... Out, damned spot! Out, I say!—One: two: why, then ’tis time to do ’t.—Hell is murky!—Fie, my lord, fie! a soldier, and afeard? What need we fear who knows it, when none can call our power to account?—Yet who would have thought the old man to have had so much blood in him?

Lady Macbeth: The thane of Fife had a wife; where is she now?—What, will these hands ne’er be clean?—No more o’ that, my lord, no more o’ that; you mar all with this starting...
Lady MacBeth: Here’s the smell of the blood still; all the perfumes of Arabia will not sweeten this little hand. Oh, oh, oh!

Morals? Lady Macbeth subsequently commits suicide. Yes, she encouraged murder, but she also subsequently became psychotic. If we were a physician in the Dunsinane ER, would we have discharged her as not "imminently a danger to herself" or would we have heard the history and reaized that there was a high likelihood of her taking her own life?

Do we stand by and watch a person commit suicide because he says, in whatever state of mind, that it is what he wants?

Anonymous said...

Roy said,

"I truly do not understand how someone would allow a vulnerable adult lacking decisional capacity to wander into the snow to die knowing her life could be saved. This seems to me to be a cruel and callous perspective. (Rob, I am not saying you are so, just that this perspective fells so to me.) I am trying to square this with my world view and just don't get it."

If this vulnerable adult was going to be taken to the place mentioned in this article, Beatitudes, http://www.nytimes.com/2011/01/01/health/01care.html?_r=2, then I would agree with you.

"Dementia patients at Beatitudes are allowed practically anything that brings comfort, even an alcoholic “nip at night,” said Tena Alonzo, director of research. “Whatever your vice is, we’re your folks,” she said.

Once, Ms. Alonzo said: “The state tried to cite us for having chocolate on the nursing chart. They were like, ‘It’s not a medication.’ Yes, it is. It’s better than Xanax.”

If the dementia patient were to be returned to a place like what this person previously experienced, I would say it is better for her to die in the snow. It doesn't sound like she was doing much living at the previous facility.

"Arlene Washington’s family moved her to Beatitudes recently, pulling her from another nursing home because of what they considered inattentive and “improper care,” said her husband, William. Mrs. Washington, 86, was heavily medicated, tube fed and unable to communicate, “like she had no life in her,” said Sharon Hibbert, a friend.

At Beatitudes, Dr. Gillian Hamilton, administrative medical director, said she found Mrs. Washington “very sedated,” took her off antipsychotics, then gradually stopped using the feeding tube. Now Mrs. Washington eats so well she no longer needs the insulin she was receiving. During a recent visit, she was alert, even singing a hymn. "
AA

Anonymous said...

All I can say is when you have experienced sexual assault which leads to depression and suicidal thinking and then you are forcibly stripped and made to relive the sexual assault complete with begging and want to still call this life saving treatment, then I say come back and talk to me. I suspect many would change their votes.

If that's the best that can be done, then please do nothing.

People want to always talk about those who are psychotic. But, this is not just done to people who are psychotic. This is also done to people who are completely in control of their faculties but are depressed. I've always had the same opinion on forced treatment and always been oriented X 4, even several years ago when I was depressed.

I fully support those who would want to sign a Ulysses contract and agree to forced treatment should you become depressed, psychotic or whatever. I would never sign it. No thanks.

Leslie

Rob Lindeman said...

LOL!!! The Tragedy of Macbeth re-written as Farce! I Love it!

[as an aside, I am enjoying this thread enormously!!!]

To fill in some background for anybody still following: Lady Macbeth, clearly more ambitious, even more ruthless, than her husband, goads Mac to kill Duncan the king, then smears his blood all over the sleeping guards to frame them for murder. Consumed by guilt for what she's done, she begins sleepwalking (at least that what she's doing according to the gentlewoman) and talking crazy-talk about the blood on her hands (in Iambic pentameter no less!)

Macbeth engages a doctor to minister to his troubled wife. The doctor, diagnosing the Lady with an affliction of the soul, rather than of the body, declines to prescribe a physic. Disgusted by her black deed and consumed by guilt, Lady Macbeth kills herself.

In 17th century England, the "signs and symptoms" evinced by Lady Macbeth were ascribed (correctly, in my view) to afflictions of the soul, rather than diseases of the brain. This is why the doctor demurs from treating her - in his world-view (and mine) she can only treat herself.

Here in the 21st century, where morals are medicalized, the Lady would indeed by hauled off, probably by her husband, to an ED, where she'd be committed (probably involuntarily: after all, she REALLY wanted to kill herself). In the moral universe of the play, commitment would be a fate worse than death.

Shakespeare's answer to Jesse's question is the correct answer: We watch the tragedy unfold and emerge, in ST Coleridge's words "sadder and wiser" for the experience.

Anonymous said...

On that note, why was Hamlet, in his suicidal state, issued a permit to carry a sword? Where has all this poison, that one can pour into the ear of a nemesis, disappeared to?

Sunny CA said...

I agree with Leslie. I felt more traumatized following my hospitalization than I had felt after any traumatic life event previously including being raised by physically abusive parents and being raped twice in my late teens. In fact, the staff was more physically abusive than my parents were and that is saying a lot. I "caused" the abuse by refusing treatment as an in-patient. That did not stop them from injecting me. There was actually no way to avoid treatment. Many of the medications administered were also traumatic to experience. I wish psychiatrists who work in hospitals would serve a week as a patient incognito in a non-teaching hospital during their residency and see what it is like.

Sarebear said...

Oh. My. GOSH. I am completely DISGUSTED that a physician (Rob) could condone ANY situation that would lead to a person killing themselves, which is what his most recent posting on Macbeth seems to be saying. I am not trying to open up the euthanasia can of worms here by saying ANY, but really I am just disgusted by Rob's position and illogical arguments for leaving someone grossly suffering from mental issues.

The other posters I can understand, but for someone who took an oath to do no harm, yet he'd let the Lady Macbeth kill herself because it's a moral problem, not a mental health one (although it seems he objects to certain kinds of treatment for mental health reasons too . . .).

One wonders if he'd have alot in common with Scientologists.

I don't mean to be so personal, but I am HORRIFIED by the implications of what he's saying.

jesse said...

Sleepwalking was often used in plays as a vehicle to portray psychosis. Yes, there is guilt, but it is portrayed in a psychotic way. The language, with the breaks of context, is evidence of this.

The real issue is that of process: If a patient who is acting in a bizarre way, possibly after a suicidal attempt, is brought to the ER by people who are concerned, how does the staff know what to do if not by history and observation? And who would be best suited to do that assessment?

This is the question that is hardest to address. If we know in advance that the problem is simply a "moral" one we have no need of a careful examination. But if we, or any of our loved ones, were to be found talking to ourselves as Lady Macbeth was, would we want those around us to wait passively for the tragedy to play out?

What do you think should be done in these instances?

Anonymous said...

Well, I think it's too bad that we don't have a psych advance directive that people could sign while they are competent that would allow them to say no to involuntary psych treatment under any circumstances and actually have that be enforceable. I would sign it in a heartbeat.

Leslie

Anonymous said...

I have the same opinion as leslie and an anomymous regarding how hospitals retraumatize people with a sexual abuse or rape history. This is my situation too, and why I spent 100 hours on my advance directive and met with adminitrators of 2 local hospitals. I also made sure all the case managers were aware of the problem and virtually every local psychiatrist has heard about it from me thru the years (there aren't very many because I am rural).

Psychiatrists readily admit that a huge percentage of their caseload are sexual assault victims, and most do seem to take in the information that coercion and searches may make the person safer in the short term, but in the long term, makes them more likely to harm themselves or get sicker.

anyway, I had some effect in doing these things, but it was at significant cost to my own psyche.

Heck, I won't even fly anymore with those airport searches, which are not as intrusive as hospital searches.

I also totally agree, it isn't only people with psychosis who are put in against their will, it is severely depressed people too. Folks are allowed to climb Mt. Everest, with about a 5% chance of dying in a summit attempt, but a bipolar or depressed person who is thinking more or less straight is not allowed to take their risks staying in the community if someone thinks they might do something. Living in the community is my Mt. Everest, ok? I freely decided that while I am competent.

Anonymous said...

anon above, that is right. the community is my mount everest. one day, minding my own business, in a slump but not in the least sudicidal i was tricked into seeing a doctor. the doc asked if i was suicidal. i said no. that was the wrong answer or it must have been because he locked me up for 72 hours to be "assessed". i objected in a reasonable manner at which point i was put into isolation and injected with drugs against my will. worse was threatened. when a psychiatrist interviewed me i was told that i was free to go because i certainly did not need to be in hospital. i also did not need to be restrained with chemicals that i did not want and did not agree to. who else but a person with a pre-exsiting psych diagnosis would be forcibly drugged when no drugs were needed? a dog? no, the humane society would stage a protest. no one protested on my behalf except for me and all that got me was a needle.

Exalya said...

It's really hard to balance who should be involuntarily treated and who should not. There are definitely people who are only hurt by being confined against their will, and I think that's something that is too-often overlooked. Like so many things in medicine, one treatment is not the solution for 100% of the population.

That aside, I think it is important that people in an acute psychiatric crisis, or those with significantly impaired function, be treated involuntarily. Roy mentioned a dementia patient, which I see as a classic case of "should not be sent home alone." The woman is not making the choice to go back home while she's sick; in this case her disease is making that choice for her.

Anonymous said...

Sarebare,

In reference to Rob, you said,

"One wonders if he'd have alot in common with Scientologists."

You have every right to disagree with him but with all due respect, this is a straw man argument and has nothing to do with his positions.

AA

Sarebear said...

It's not an argument, it's a statement that reflects my level of . . . incredulity at his "arguments". I can't even give them credence, just as I can't give the Scientologists credence in the area of mental health (or some others, but that's beside the point).

It was more of a personal jab, not that he'd necessarily be insulted by it, and for THAT reason, I should have not said it.

This whole "straw man" thing I find to be a bit of intellectual hoighty-toighty-ness that people accustomed to vigorous debate do, and I find it rather patronizing and not serving much purpose.

But what's the point of debating how to debate lol, I just admitted I shouldn't have said that statement, and I apologize to Rob for it now.

Anonymous said...

If there can be a tin man, there can be a straw man. It would be nice if there were some tin and straw women, too.

People should be allowed to debate at their own level, whatever that is. After all, as someone once said, everyone's entitled to their opinion. But, you can't take mine.

Anonymous said...

Hi Sarebare,

I am sorry you found what I said patronizing. I certainly didn't mean to come across that way and perhaps I could have found a better way to make my point.

I think I am coming at it from the perspective that the scientology argument is really getting old in this type of debate and serves no purpose. I guess I should have stated it that way vs. using the strawman argument.

Point well taken.

Thank you for recognizing that what you said was a personal jab at Rob.

AA

Rob Lindeman said...

Folks, why are we continuing to bracket schizophrenia with dementia? The latter is a neurological entity. The former is not.

If schizophrenia were a neurological disease, wouldn't neurologists "manage" schizophrenics?

Rob Lindeman said...

Back to involuntary incarceration: With respect, Exalya, it's NOT hard to know when to incarcerate an innocent individual against his will. The testimony of several commentators here ought to suffice to answer your question, but you needn't rely on anectdote.

Remember your oath to do no harm. Involuntary incarceration of the innocent violates the dignity and personhood of the individual. You injure the person whether or not he thanks you later for his injuries.

Anonymous said...

Take away the bullying by any member of the hospital team, take away the harsh lights, take away the humiliation of the backless gowns, put in some people who come with an empathic approach not a confrontational or judgemental one, give people acccess to toothpaste or a blanket to stay warm. Don't have them wait for days until somemone sees them. Take it all out of the hosptial to community places staffed by people who give a care and maybe more people would seek help voluntarily or accept it.

Roy said...

"Folks, why are we continuing to bracket schizophrenia with dementia? The latter is a neurological entity. The former is not. If schizophrenia were a neurological disease, wouldn't neurologists "manage" schizophrenics?"

Now you're just trolling, LOL.
Schizophrenia has long been known to be a neurodegenerative condition. Discovered by neuropathologist, Emil Kraepelin, the psychosis of "dementia praecox" was differentiated from that of manic-depressive illness. Kraepelin, along with colleague Alois Alzheimer, also discovered the nature of senile dementia, and named the disease after his colleague. Eugene Bleuler later renamed dementia praecox to "the schizophrenias" in recognition of the fact that degeneration sometimes did not occur.
The idea that the nature of a disease can be defined by the specialty that treats it is inaccurate. Psychiatrists become board-certified in psychiatry and neurology, as do neurologists, and both treat dementia. Decidedly fewer neurologists treat schizophrenia nowadays.

It's taken me this long to realize this discussion is just going in circles, so I will disengage.

Rob Lindeman said...

Sheer nonsense.

Schizophrenia is NOT a neurodegenerative disease. There is no neuropathological lesion whatsoever! Kraeplin may have been a pathologist (was he?) But the disease he invented has no pathological correlate.

And if it were a degenerative disease, why was it treated with lobotomy and electroshock, which ACTUALLY damage brains?

Anonymous said...

Regarding lady MacBeth, I agree with Rob Lindeman: Her problem was a moral predicament not a medical one. Agitation and blathering and ritualistic hand-washing over soliciting murder are not the same things as the agitation accompanying mental illness. If she's suicidal, she needs family, peer and pastoral support. Psychiatry can't help everybody and it shouldn't try, IMO.

Anonymous said...

About Lady Macbeth, imagine she was taken to hospital, given some meds and thanked everyone for helping her regain her life. That would be an advert for a drug co, not a play.

Rob Lindeman said...

In re Emil Kraeplin:

http://en.wikipedia.org/wiki/Emil_Kraepelin

Not a pathologist. Never found pathology in dementia praecox

moviedoc said...

Apparently in San Francisco they believe in "Live and let die." Should a psychiatrist have rescued him?

http://www.msnbc.msn.com/id/43233984/ns/us_news-life/

Alison Cummins said...

Rob Lindeman,

If you don't think that schizophrenia is a brain disease, what do you think it is?

Rob Lindeman said...

Allison,

To do justice to your question requires a lot of space. With apologies I'll give the "comments section" version of an answer.

Schizophrenia is a label we place on people whose speech we don't understand and whose behavior irritates us - we use this label to justify removal of such people from public view and to justify excusing such people from punishment for commission of crimes.

What do YOU think it is?

Anonymous said...

Rob is saying that schizophrenia was invented. It isn't an illness. That's outrageous. Maybe he is a troll.

Alison Cummins said...

Schizophrenia is a brain disease.

Sarebear said...

Rob's never going to listen to reason; this is why I think Roy disengaged. It's why I did too, unofficially. Doing so officially now.

Anonymous said...

Moviedoc writes, "Should a psychiatrist have rescued him?

http://www.msnbc.msn.com/id/43233984/ns/us_news-life/"

If it were me and I were in that situation, I would not want a psychiatrist to intervene. I have experienced what happens when they intervene against my wishes, and not only was it not life saving it made me more despondent. I would imagine if you had asked him if he wanted someone to step in and forcibly strip him, put him in a cage, threaten him, and then let him go he would probably have wished to decline psychiatric services.

Leslie

jesse said...

There are quite a few people, like Leslie, who have had such negative experiences with psychiatric hospitals and psychiatrists that it has left them with profoundly negative views not only of the field but of the discipline as well. These are intelligent people who look beneath the surface of things. We need to find a way to address these perceptions of psychiatry in a blog of it's own. Ideas?

Anonymous said...

It is really important for patients to know their rights when it comes to inpatient psychiatric treatment. If anyone ever finds themselves in teh situation I did where you are being threatened that if you do not sign an informed consent document and "agree" to a voluntary admission they will do it for you, be sure and get everyone's name and commit to memory exactly what is said. If threats have been used to obtain informed consent, they have violated your rights, and you can take legal action.

By signing an informed consent document the physician is saying the patient is competent to consent (or not) to treatment and for consent to be valid it must be done without threat/coercion.

Obviously, if a patient is not competent to sign a consent form, then they should not be signing one in the first place. If you do take legal action later, the psychiatrist will not be able to hide behind the "it was an emergency and she wasn't competent" argument - because their response will be, then why did you have her sign the consent?

A good resource (in Texas) is Advocacy Inc - they are a group of attorneys that represent patients with disabilities and can help with this kind of stuff. I would imagine other states have similar organizations. Forget the hospital patient advocates, they have an interest in protecting the hospital.

You can also file a complaint with the state nursing board (if the nurse is the one making the threat), the state medical board, JCAHO, etc. Remember, no one has the right to threaten you to sign consent.

Leslie

Anonymous said...

Jesse, I want to clarify that my issue is with forced treatment not with psychiatry as a whole. I support those who voluntarily seek psychiatric care.

I do think what would help with this is to have a way for competent people to have enforceable advance directives which allows them to opt out of psychiatric treatment should an emergency arise. Because in medicine, competent adults should be able to decide what they do and do not want to happen to them.

Leslie

Dinah said...

Looks like we did a podcast on Forced Treatment:
http://psychiatrist-blog.blogspot.com/2007/05/my-three-shrinks-podcast-22.html