Tuesday, June 07, 2011

What's Really Insane

There's a great post up on Pete Earley's blog entitled "What's Really Insane? Our System" that outlines the conundrum of our mental health system from beginning to end. He starts out by discussing the Jared Loughner case and the difference between hospitalization for treatment versus hospitalization for restoration of competence. Among forensic psychiatrists we call this "clinical competence" (reduction of symptoms, restoration of function) versus "legal competence" (the mental capacity to participate in a legal proceeding). While he says these are two separate and distinct issues, in fact there is a correlation between mental capacity and symptomatology. I'm running late this morning and don't have time to post citations, but off the top of my head I remember reading some articles that correlate BPRS (a symptom scale) scores with evaluators' assessments of legal competency. In other words, treating someone's symptoms will improve and restore competency. That alone isn't always enough though, which is why forensic inpatients are also often involved in competency restoration groups to target that specific issue.

Earley does a nice job of outlining the problem of involuntary medication in some criminal defendants; in Maryland it's a particular problem due to a Court of Appeals decision that the person has to be dangerous in the hospital before they can be treated. Thus, someone could end up institutionalized for a very long time awaiting trial.

That's an incomplete summary of a very good post. Surf over to his site and read the full piece.

60 comments:

Rob Lindeman said...

From the Earley piece:

"What’s missing from this tragedy is our legal system’s own complicity in the murders that Jared Loughner committed."

Nonsense. Statements like these demonstrate how far and fast we've fled from the concept of personal responsibility. Now, not only is Loughner not guilty by reason of insanity (does anybody doubt this, should he ever get a day in court?) but instead WE are complicit in his crimes!

No thanks, I plead innocent

Dinah said...

Thanks for finding this, Clink. Early does a great job of identifying all the troubling dilemmas our society is creating. Do they really have prisoners point to chairs to restore competency?

Rob Lindeman said...

(I should fill in the reasoning here)

...and why are WE complicit? Because we refuse (with wisdom, IMO) to empower to the State to incarcerate innocent people prior to the commission of crimes, or to treat them against their will.

jesse said...

One problem is the one outlined. The complicity of society in the Loughner case, however, has more to do with the ability of an individual in any state of mind to buy assault weapons than with the ability of physicians to medicate someone against his will.

Rob Lindeman said...

"The complicity...has more to do with the ability of an individual in any state of mind to buy assault weapons"

Easy access to firearms is an issue to be sure, but it isn't the issue Earley is addressing. In his summary paragraph he says:

"On one hand, we refuse to help someone when they first begin showing sings of becoming mentally unstable".

Earley is making a classic "right-to-treatment" argument. In other words, he believes we should coercively treat people who don't want treatment and who don't even believe they are ill!

I don't believe anyone, even in Arizona, refused to treat Jared Loughner. I think Loughner didn't want to be treated.

jesse said...

There will be pressure from the public to "do something" when someone as clearly psychotic as Loughner shoots a lot of people. The reaction can be to limit access to weapons, to focus on the mental health system, or both. Given the determination of much of the public to keep access to firearms as unfettered as possible, emphasis might shift to loosening the criteria for forceable medication of the mentally ill.

Rob Lindeman said...

As a rule, catastrophes present opportunities for the State to enlarge its sphere of influence at the expense of individual liberty (see 9/11)

Anonymous said...

"[The] emphasis might shift to loosening the criteria for forceable medication of the mentally ill."

Do you want to be the person that decides to forcibly drug someone? Do you have that kind of belief in your own wisdom?

In the law there's a saying that it is better that ten guilty men go free than that one innocent man should suffer. So how many tens, or hundreds or thousands of otherwise peaceable mentally ill persons would you forcibly drug in order to chemically capture and restrain the one that might be dangerous?

I'm just wondering what your calculus is here. And I'm wondering whether your thinking might be different if we were talking about preemptively imprisoning people who we think might be dangerous.

If there were an algorithm that could predict future violence in 80 out of 100 non-mentally ill people, but couldn't predict exactly which 80 would be violent, would you be willing to imprison all 100 of them? How about 90 out of 100? Does your answer differ depending on whether you're talking about street gang members or the mentally ill?

Anonymous said...

Jesse said,

""Given the determination of much of the public to keep access to firearms as unfettered as possible, emphasis might shift to loosening the criteria for forceable medication of the mentally ill.""

And when this happened in the state I live in, people who were in the mental health system were scared to death to seek treatment out of fear they would be medicated against their will.

I mean no offense but this situation reminds me of George W using 9/11 as justification for going to war in Iraq when Sadaam Hussein was not responsible for the horrific catastrophe.

Even when the crimes have nothing to do with the issue of whether someone got treatment or not, the states and people like Fuller Torrey and Early use this opportunity to advance their agenda of forcible medication treatment. I find it very frightening.

AA

AA

jesse said...

To anonymous, I read the sentence I wrote below several times:

"Given the determination of much of the public to keep access to firearms as unfettered as possible, emphasis might shift to loosening the criteria for forceable medication of the mentally ill."

Is there anything in it at all that indicates I would want to loosen the criteria for forced medication? No, No, there is not and I do not. There is nothing I ever posted that indicates I would take that position.

Again, what is clear is that there will be no serious effort to restrict access to handguns. The "right" for easy access to handguns, to many people in this country, will trump the right of the individual to refuse medication. I do not like this. I am merely calling it the way I see it happening.

One set of "rights" will be bought with the other.

Anonymous said...

Sorry Jesse, I didn't mean to imply that you were for forced medication.

I was just trying to point what the consequences would be and how ridiculous this situation has become.

AA

Anonymous said...

Jesse--thank you for the clarification. I didn't mean to mischaracterize your statement.

As for the issue of the need for more gun control, I suspect we disagree on that. But that's a much longer discussion than I have time for right now.

First Anonymous

Rob Lindeman said...

Jesse,

I read THIS sentence several times and I still don't understand it:

"The 'right' for easy access to handguns... will trump the right of the individual to refuse medication."

The former right cannot trump the latter because they are not mutually exclusive, as in "my right to privacy trumps your right to aim a telescope at my window"

Anonymous said...

The movie Minority Report is an awfully close analogy to forcing treatment on persons with mental illness because they "might" be dangerous. The whole idea of incarcerating people based on the prediction of psychics was very offensive, even if they were always right (which they were NOT)but that is what is done to people with serious mental illness, even many of those who KNOW they are sick. Psychiatrists admit they can't tell any better who will be violent than anyone else. And yet it is on your record forever, and you are in an FBI database, when maybe your problem was you were too depressed to feed yourself.

Anonymous said...

To Rob,

I am grateful that I am not an American and that we do not have easy access to handguns, irrespective of our mental status.

Why did you land here and do you have any plans to leave soon?

Yes, I would say that to your face anytime, anywhere. Just call me cockraoch. That trumps a flea.

Anonymous said...

cockroach

moviedoc said...

Dinah: No one thinks the chair thing restores competency. It's just a test. Another key question is whether the defendant is capable of assisting his attorney in his defense.

Rob: I don't believe we have established that Loughner didn't know the difference between right and wrong when he did the deed, or whatever the insanity test is in AZ.

This is a tough balancing act. Part of me believes we should be more willing to treat people against their will, but I don't like the idea of psychiatrists being the bad guys for society either.

jesse said...

Clink, one particular thing in the Early article seems inaccurate.

Early wrote: "In short, we are currently in the process of taking the necessary steps to make him well enough so that we can execute him for crimes that he committed when he was so sick that he didn’t know what he was doing."

Once a person becomes competent to stand trial, cannot the result of the trial be that he is found to have not been sane (could not tell right from wrong, could not control his actions, I'm not sure what the criteria are) at the time of the offence, and so is not sent for punishment but for treatment?

But the basic point of his piece is something that is a very pertinent issue here. It is that society exacts consequences, and mentally ill people are regularly sent to prisons where they receive no treatment at all (with or without medication, given voluntarily or not).

jesse said...

Whoaa, moviedoc and I wrote almost exactly the same thing. Independently. But let's not get carried away by this.

jesse said...

"In Maryland it's a particular problem due to a Court of Appeals decision that the person has to be dangerous in the hospital before they can be treated." He means forced to take medication.

An Administrative Law Judge I know told me how upset she was by this. It is now the law. However dangerously crazy a person has been outside the hospital, no matter the extent of his violence, no matter how connected the violence is to his psychosis, as long as he does not show that dangerous behavior inside the hospital, he cannot be medicated against his will.

Anonymous said...

Why is it that the docs commenting here sound hypomanic? If they had a bipolar diagnosis in their chart, they'd all be in hospital, doped up on one drug or another by now.

Source: Experience

moviedoc said...

What I think is really crazy is that one could be restored to competence, stand trial, and NOT be found not guilty by reason of insanity and sentenced to death. Then the separate question of competence to be executed might arise. Seems to me less cruel to be executed when you're out of your mind.

This link to a relevant article just found its way to my in box:

http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_871274.html

Duane Sherry, M.S. said...

Due process.

“Mental health" cases need to be taken for what they are.

Legal cases.

And they each deserve due process of law.

The prosecution has a role - to protect citizens, the county, the state, the people.

It also has a "burden" - to prove someone is an iminent threat (not a perceived threat... not psycho-babble). It has the role of making sure dangerous people are put away... not ones who are harmless, but misunderstood.

The defense has a role as well – to provide the best counsel possible for their client. To serve as a true advocate on their behalf.

It is not psychiatry’s role, or that of a social worker to insist that a person “lacks insight” and deserves to be placed in a hospital (incarcerated) based on their “medical opinion” of what’s in their best interest.

We need to have these cases heard in real courts... not "mental health courts (the kangaroo variety).

Unfortunately, the mental health court system is a place where attorneys are lucky to have 24 hours to prepare for a case, and the judges are often connected to the treatment network..."good-ole boys", friends with doctors and other mental health staff in their community.

We have over 3 million people in this nation who have been diagnosed with “schizophrenia.” To say that the vast majority of these folks are peaceful is a masterpiece of UNDERSTATEMENT. They are much more likely to become victims of crime than perpetrators.

They need protection.

And each person involved deserves "due process" as guaranteed in the 14th amendment to the Constitution.

The system we have now makes too many assumptions. And the person who finds themselves in a mental halth court does not have adequate counsel.

Judges and juries need to hear the facts of each case.

These are not "medical decisions."

These are cases where an individual's very freedom rests in the balance.

I welcome the day when we give a jury the opportunity to hear these cases.

Not just the high-profile ones...
Each of them.
All of them.
One at a time.

In other words in real trials juries would begin to hear the OTHER SIDE to treatment "advocacy".

Juries could hear from witnesses who are quite likely to say these kinds of things -

"He was doing fine, until he was placed on an antidepressant, and then he seemed to change... He had no previous history of violence, until he started taking Paxil."

"She had a tough time after her child was abducted... She couldn't sleep for a week... That's when she started acting strange... We were scared for her"...

"On his third tour of duty, he saw a psychiatrist, who insisted he had a mental illness... These words upset him... He became hostile."

"It's not as though he hasn't receieved treatment before... The treatment seemed to make things worse for him... It was on the drugs, and then off the drugs... and each time he went off, he got worse… He has insisted for years that the drugs are making things worse, and wants help getting OFF of them.”

Once juries begin to hear some of these kinds of testimonies (and they're out there), attorneys will be in a position to mitigate.. To ask for alternative treatment centers.

Ones that offer hope -

http://discoverandrecover.wordpress.com/mental-health-freedom-and-recovery-act/

Duane Sherry, M.S.

Duane Sherry, M.S. said...

Involuntary Committment and Forced Psychiatric Drugs in the Trial Courts -

http://www.law.duke.edu/shell/cite.pl?25+Alaska+L.+Rev.+51

Duane Sherry, M.S.
discoverandrecover.wordpress.com

Rob Lindeman said...

From the AP (yesterday):

"TUCSON, Ariz. (AP) — The Tucson shooting rampage suspect's lawyer says she's unable to provide discovery requested by prosecutors until her client is declared competent to stand trial.
In a Monday filing, defense attorney Judy Clark says the court's finding that Jared Lee Loughner is incompetent to stand trial makes it clear that she "cannot have rational or meaningful communication" with him.
She says she also cannot consult with him about any possible defenses or evidence that may be presented at trial until he is declared competent."

Presumably, Clark has spoken with Loughner. Can't she make the determination herself that she can or cannot consult with him about possible defenses? Why does she need the court to make the determination? The answer is, she doesn't need the court. This is a strategy to delay the trial as long as possible. That's the strategy most likely to favor Loughner (NGBRI).

By the way, I'm amused by the idea of the accused being "rendered competent" to stand trial, found guilty and executed. I doubt that has ever happened.

Anonymous said...

"By the way, I'm amused by the idea of the accused being "rendered competent" to stand trial, found guilty and executed. I doubt that has ever happened."

I don't know if this has ever actually happened, but I do know that it's a legal possibility that a person accused of a death-eligible crime, who is found incompetent to stand trial, could be treated to competence, found guilty, and sentenced to death.

Whether the sentence would ever be carried out is a different matter.

Anonymous said...

It won't do any good to have jury trials for involuntary treatment hearings. I remember reading that in jury trials, if a person is convicted but it is explained to the jury that the person had mental problems and therefore had diminished responsibility, the jury wanted a LONGER sentence. I read this some time ago, and do not remember where.

I philosophically object to the lack of a jury trial, but as a practical matter, I think a judge may be less prejudiced.

Duane Sherry, M.S. said...

Anonymous,

I've have the opportunity to talk with Attorney, Jim Gottstein on several occasions over the years.

He was successful in a couple of cases, where the Alaska State Supreme Court ruled in favor of the person deemed "mentally ill".

I think that if you spend time on this article from Duke Law, it may give you some hope -

http://www.law.duke.edu/shell/cite.pl?25+Alaska+L.+Rev.+5

Also, MindFreedom has an online 'Forced Drug Defense Package" -

http://www.mindfreedom.org/shield/forced-drug-defense-pkg/defense-package.

I hope this helps,

Duane Sherry, M.S.
discoverandrecover.wordpress.com/freedom

Anonymous said...

It wasn't 10 minutes after this happened that E. Full of it Torrey was on TV again using this to promote his forced medication agenda. Scary stuff.

I have also seen Earley on various programs, and I'm not a fan. They both seem perfectly ok with infringing on the rights of people who have not committed a crime on the off chance that it might prevent one person from doing so. Yikes.

But, why stop with those diagnosed with mental illness, with one in four (or is it 5) having a mental illness at some point in their lives, shouldn't we just medicate everyone to be super safe? With mental illness lurking around every corner, imagine how many violent acts we could prevent if we just forced every single male in their teens and twenties and every new mom to take Vitamin H? Poof! Violence would just disappear.

Leslie

Duane Sherry, M.S. said...

Psychiatry tries to paint itself as the protectors of the most vulnerable....

Concerned that the "mentally ill" get "proper treatment"... as opposed to incarceration, and/or "further deterioration".

Always the "either/or" scenario...

They "care."

Keeping in mind, the APA (American Psychiatric Association) has 38,000 members, I have to ask myself -

"Where are all these caring people when it comes to drugging children?... some as young as 3 years-old" -

http://bipolarsoupkitchen-stephany.blogspot.com/2011/06/prescribed-antipsychotics-at-age-3.html?showComment=1307490970962

If the field of psychiatry "cares" so much... then where are the 38,000 members! Where are they?

It's a profession that has proven it cannot police itself... And the profession continues to ask us to trust their judgement in the area of legal procedure... issues of freedom...

Really?
How arrogant!

The field has a history.
One of silence.
They're silent.
That's "where" they are.

... And the constant mantra of "danger to self and others"...

The Jared Loughner tale... again and again...

The extreme case.

While ignoring the stronger case...

Namely, that the overwhelming majority of people diagnosed with "schizophrenia" (a dehumanizing label) are peaceful, living quietly in their communties... many of whom have had all the labels and "treatments" a person should be allowed to undergo!

If psychiatry wants to continue to bring up the extreme cases, why not start with one of their own? -

Namely, Army psychiatrist Hasan...
The Fort Hood Shooting -

http://articles.cnn.com/2009-11-05/us/texas.fort.hood.shootings_1_gen-robert-cone-nidal-malik-hasan-fort-hood?_s=PM:US

Here in Texas, we suffered an enormous loss.

13 killed.
29 wounded.

Until such time as psychiatry learns to police its own, it has no business policing others, or "protection" others... especially some of the most vulnerable in this country!

Duane Sherry, M.S.
http://discoverandrecover.wordpress.com/freedom

Duane Sherry, M.S. said...

Correction.

12 dead.
31 wounded.

Duane

Anonymous said...

Duane, that's a good point. Not only do we have the problem with the violent psychiatrist at Fort Hood, the psychiatrist I saw had a couple of arrests under his belt, and another one who had privileges at teh same hospital was under a state board order for sleeping with psych patients. Clearly, the compassionate thing to do would be to forcibly medicate all Texas psychiatrists. I would hate for a single psychiatrist in need of help to go untreated. ;-)

All joking aside, it's a very dangerous thing to base forced treatment on a guess of what someone "might" do.

Leslie

Rob Lindeman said...

LOL, Leslie!

It reminds me of "The Thanatos Syndrome" a terrific novel by Walker Percy, about a town where radioactive sodium is purposefully "leaked" into the water supply, rendering everybody happy (and horny, as it turns out)

"All [citizens] exhibit suppressed cortical function, manifested in strange speech patterns and sexual behavior.. [The protagonist] discovers the source of this syndrome: the town's drinking water has been laced with heavy sodium from the area's nuclear facility. Leading citizens of the community are involved, all in the name of benevolent eugenics and social concern."

Hey Torry and Earley, didja read it?

Duane Sherry, M.S. said...

And Leslie takes the gloves off -

"Clearly, the compassionate thing to do would be to forcibly medicate all Texas psychiatrists. I would hate for a single psychiatrist in need of help to go untreated. ;-)"

I love it!

Duane

Rob Lindeman said...

Off the web, today:

http://www.pennlive.com/editorials/index.ssf/2011/06/real_cost_of_budget_cuts_goes.html

Money Quote: "Loughner suffers from schizophrenia, delusions and major medical illness"

I'm guessing the author included "delusions" and "major medical illness" to emphasize that Loughner is really REALLY sick!

Duane Sherry, M.S. said...

Rob,

An what diagnosis (diagnoses) should psychiatry be given, for all the injury they've caused along the way... the disregard for human life?... without remorse?

'Sociopathic' comes to mind.

Duane Sherry, M.S.
http://discoverandrecover.wordpress.com/warning

Rob Lindeman said...

I dunno, Duane, I'm quite sure that most psychiatrists are secure in the conviction that they're doing good work. The problem arises when they do this work on behalf of individuals who don't want their assistance, or when they excuse criminal and otherwise bad behavior by means of diagnoses

Dinah said...

Dear Duane and others,

I am an outpatient psychiatrist and treat only voluntary patients.

I believe my patients would tell you that their treatment is helpful, and many of them feel the medication aspect of their treatment has been life-saving and helped them to feel much better. Those who don't feel that way stop their medications, and those who don't find what I have to offer to be helpful stop coming. The people I see often come in a state of distress, find treatment to be beneficial, and leave feeling better.

I find the vehement discussions against medications as being insulting to those who find them helpful and want to take them. Psychiatry is about more than a prescription pad.

None of the Shrink Rapper see children in any setting or have had child psychiatry training. No child psychiatrist I have ever talked with has told me they prescribe psychotropics to 3 year old children. They doesn't mean it doesn't happen, but Shrink Rappers are not at liberty to burst in to the offices of other psychiatrists and demand to look at their files. None of us has ever lived in Texas or been in the military or had idea that the Fort Hood tragedy was going to occur. You all seem to hold all psychiatrists responsible for the behaviors of other psychiatrists.

---to be continued---

Dinah said...

==continued from above===

I started Shrink Rap because I love to write and I like talking about my work. It is a strange field we have where there is so much controversy and so much uncertainty about how best to treat patients. There’s also the issue that people react differently—to medications, to words, to the way they were treated. If you read our book, or even just the reviews of it, you’ll see that while we are mainstream psychiatrists, we address head-on that psychiatry has shortcomings.

You've apologized to another commenter for upsetting them with your comments, so I'm perplexed at your hostile tone towards us Shrink Rappers. We're people who like our jobs, like to write and play with technology, and it feels to me-- and I may be wrong-- that you've decided we're evil people and so it's okay to be overtly hostile, aggressive and insulting on our blog. The funny thing is that we are the ones saying there should be more open dialogue and trying explain our work in a way that we hope will effect positive changes. Perhaps understanding will lead to empowerment by patients-- that would be great! You don’t need to agree with us, but if you’re going to stay here, then at least be respectful of our work.

Recently, the Shrink Rap comment section has become a fairly ugly place to hang out. We talked just briefly about moderating or closing the comments, but that would defeat the purpose of the blog, so it’s not going to happen. However, incessant, repetitive and hostile comments towards psychiatrists doesn't do anything to open dialogue and I believe you have shut down discussion. We have been happy, for more than five years, to have readers come to our comment section and simply share their stories, even if they are painful ones, even if they are angry and have distressing stories about psychiatry. Until we started Shrink Rap, I had no idea there was such strong opposition and distress towards psychiatry.

The readership of the comment sections of blogs is fairly low---perhaps handfuls. I'm not sure how commenting here will change the world, and you clearly would like to change it. Is there not some more powerful venue then this to invest your time and energy?

If I can take a guess, I would anticipate that Rob might say I have a no-not-me attitude and perhaps that troubles him. I'm not sure what anyone would like me to personally take responsibility for, aside from Shrink Rap, where lately it feels like every word gets dissected and attacked, be it mine or anyone elses' and I find it sad that all the hostility of our comment section may be serving to stifle opinions other than those of the most hardy. I hope Sarebear and others will come back, and Jesse asked me where the other psychiatrists are, and I imagine they’ve moved to more welcoming places.

Dinah

Anonymous said...

In all fairness, this post mentions involuntary medication so it makes sense that people are going to have strong opinions about that. If it were about voluntary treatment by patients who wanted it, then there would be no debate from me.

I understand you are outpatient and treat only voluntary patients, but that's not what this post was about. I have no issue with patients who seek out treatment voluntarily and have said so on multiple occasions.

Leslie

Anonymous said...

And for what it's worth I have commented off and on since near the beginning of this blog. I just never picked a name. Found it through Doctor Anonymous back in the day, so it's not like I'm new here. I find the debates interesting. I think it would be boring if we all agreed.

Leslie

jesse said...

One tendency I've noticed on the blog is for a writer to go from his or her own experience with involuntary treatment and forced medication to generalize not only about all patients but all of psychiatry and all psychiatrists. That does not lead to useful dialogue.

I, like Dinah, do not treat any patients involuntarily. When we talk about a person's consent for anything, we have to ask how we judge whether a person can give meaningful consent. Leslie, for instance, has (rightly, in my view) pointed out that a person in therapy may become so attached to a therapist that then her consent is not really free if she is asked permission for her case to be taped. Or, most certainly, if the therapist wants to date his patient, the consent is not valid.

So if we can agree that the consent of a fully functioning, successful patient can be compromised, why is it hard to acknowledge that the consent of a person hearing voices, seeing demons, believing her skin is rotting off and that she is really the devil incarnate, can be even more invalid? and if it is invalid, what should be done in the most extreme cases, not in the least?

I have learned a lot reading this blog. There are quite a number of intelligent and perceptive people posting their experiences. But the all-encompassing attacks on psychiatry as a profession are less than helpful. They drive away other visitors from this site whose voices also should be valued.

moviedoc said...

I think we should view Duane as a challenge. He wants to throw the baby out with the bath water and sees psychiatry as monolithic (which it is not). Having read his posts at Steve Balts blog I know he doesn't hate all psychiatrists. I can empathize with him based on his earlier comments. We should all work on not taking anything he says personally, and try to bring out the best in him. I agree with much he says. Imagine if we could harness that passion. We psychiatrists certainly don't know it all yet, don't have all the problems solved. I'll bet Duane will help if we give him a chance.

Duane Sherry, M.S. said...

"If everyone is thinking the same thing, then somebody isn't thinking."

George S. Patton

Anonymous said...

Jesse, not sure if you are speaking about me, but just in case, I really don't believe I have used my own experience with involuntary treatment to generalize about all patients and all psychiatrists. I understand there are people who post who hate all psychiatrists - I am not in that camp. My tongue-in-cheek comment about forcibly treating all Texas psychiatrists, and all men in their twenties and all new moms was written not because I believe it should happen but to illustrate why I think it's a bad idea to soften the laws and make it easier to forcibly treat (not saying you or anyone else here supports softening the laws but there are many like Torrey, et al who do). In fact, Earley himself admits to lying and saying his son threatened his life to get him admitted because he didn't meet the criteria for admission. That's like me deciding to break into a supermarket and steal all the food so I can feed people who are starving and arguing in defense of the greater good. I don't agree with that line of thinking.

There is a lot I do not share here, but in my own defense I have witnessed the informed consent process I would imagine over 100 times over the years (since my hospitalization), and due to my own experiences my graduate work was in the area of health care ethics. I focused on informed consent, and I am very passionate about patient rights.

I do not have any issue with voluntary outpatient psychiatric treatment as long as it is truly voluntary and people aren't being threatened or coerced - I think most of the time outpatient care is truly voluntary and that's fine. So, no one who treats only voluntary psychiatric patients should take what I say personally because that's not what I'm talking about. I had a therapist post-inpatient psych treatment who I think the world of and who helped me tremendously in the aftermath - she doesn't hate psychiatrists either and shares my opposition to involuntary treatment.

Jesse, you ask why it is hard to acknowledge the consent of someone who is hearing voices. That is a very good question. Why would a physician have someone who is hearing voices sign consent if they felt the patient was incompetent? It seems to me that if the physician feels the patient is incompetent they would understand that pressuring and/or threatening a patient to sign consent is not ethical. And, I think that's very often where I have most of the issues with inpatient care - if the psychiatrist believes the patient is so ill that they cannot make decisions for themselves then why in the world would they have them sign consent for inpatient treatment - I just don't get it.

If I have dementia and I think it's 1946, I don't sign an informed consent. Period. There is no cajoling or threatening the patient to sign - if they're not oriented they don't sign. There's no, "If you don't sign then we're going to have to sign for you and put you in the nursing home." I have never once seen someone with dementia who was not oriented pressured to sign a consent form. It would be unethical to do so. Yet, I have experienced and observed psych patients being threatened or coerced into signing consent forms for inpatient treatment. Now, maybe it just happens in Texas, I don't know. Do all psychiatrists do this when admitting patients? No, they don't adn I don't think it's an issue at all in outpatient treatment (with the exception of AOT). So, when there's a post about involuntary treatment, I think it's very important to address patient rights.

I think it's as Roy mentioned once, many times the disagreement is about where to draw the line. I would err on the side of a patient's right to make decisions if they're oriented X 4 and not committing crimes.

Leslie

jesse said...

Leslie, I was not addressing you at all and I think you are making very good points. Very clear. It is indeed a contradiction to consider a person unable to sign consent but then pressure them to do so. There are many contradictions, none of the systems work perfectly.

moviedoc said...

Leslie: Competence is more complicated than that. A person who is hearing voices could be quite competent to decide to whom they wish to leave their estate, or to assist their attorney in their defense. (Let me hasten to add that all docs face the dilemma of whether a patient is competent to consent to treatment.) Competence to consent to treatment would hinge on whether the patient understands the treatment, the illness or symptoms, the potential adverse effects, and the likely outcome of no treatment. Not knowing what year it is might be irrelevant. As a forensic psychiatrist I have evaluated individuals for testamentary capacity and competence to stand trial. It requires as much as 2-3 hours interviewing the patient, reviewing records, talking to other people, etc. More importantly I would never perform such an evaluation on a patient I was treating. Such an evaluation must be scheduled weeks in advance and is not cheap. So us treaters fly by the seat of our pants, usually assuming a patient is competent, and most probably are.

jesse said...

"I think it's as Roy mentioned once, many times the disagreement is about where to draw the line. I would err on the side of a patient's right to make decisions if they're oriented X 4 and not committing crimes."

In general I agree with the standard being to err on the side of the patient's right to make decisions unless he is deemed an imminent danger to himself or others. And now in Maryland he cannot be medicated involuntarily unless he is shown to be, in the hospital, right then and there, dangerous.

I know quite a few people who made serious suicide attempts, were saved by good medical care, and then went on to be able to live successful, happy lives. If we were to say, "look, he chose to die, why are you trying to revive him?" are we not preventing that person from changing his mind? A person who has small children he loves dearly and later is so glad he did not leave parentless, with a parent who suicided?

So, Leslie, I support the advocacy you are doing. It is important to call attention to these issues. You are writing about forced medication. This is another side of that difficult question.

jesse said...

This sentence is inaccurate: "In general I agree with the standard being to err on the side of the patient's right to make decisions unless he is deemed an imminent danger to himself or others."

I believe it is that the patient can make all sorts of decisions under those circumstances, save those that continue the dangerous behavior involved. He can be hospitalized involuntarily if he meets those criteria, and only those criteria. If this is wrong please correct me.

Anonymous said...

@ Jesse, ok, cool. :-)

Leslie

Anonymous said...

Jesse, I meant ok, cool to your earlier comment not to the latest one. ;-). On the later one, I would have to respectfully disagree because I think it's too subjective.

Leslie

Anonymous said...

What I like about this blog is that there are so many different and passionate viewpoints. I am glad that Duane and Rob post here, I think they spur debate and debate is good. I also like to read the other side of things, too, because it challenges my thinking and opinions. THere's room for all, I think. Well, maybe, except for the scientologists (only kidding).

Jesse, okay, let me try again. I'm a little slow tonight in the area of comprehension. Yes, I would agree that the laws make it possible to hospitalize someone against their will if they are determined to be a threat to self or others. But, I don't agree with that law and would like to see it change to prohibit involuntary hospitalization of people who are oriented and who have committed no crime. I think the "threat to self or others" is too subjective and too broad. I don't think it's right to hold someone against their will if they are oriented and have done nothing wrong. I do believe there is such a thing as rational suicide, although I know many will not share that world view. I think someone can be depressed and fully understand the ramifications of destructive decisions.


@ Moviedoc, I typed out a response to you earlier but then my laptop froze. Sigh. You raise some important points that I want more thoroughly address, but now I'm sleepy. I will try again tomorrow. For now, Zzzzz....

Leslie

Sunny CA said...

I have been feeling that many comments posted here recently are angry and aggressive and are destroying the blog. I don't think it would be out of line to start to prescreen posts made here, or allow readers to flag posts as having inappropriate content.

Some of the posters seems to want to change the face of psychiatry, so I think it might be more worthwhile for them to write editorials for newspapers, articles for newspapers, a book, or a blog of their own. If they don't wish to do that, then perhaps consider that we have read your point of view... about 20 times.... and it is time to go. The more hostile you (all 3 of you) are, the less I regard what any of you say with credibility.

Anonymous said...

I totally agree it is important to use civil language at all times no matter how you feel about an issue. And again, I am quite appreciative of the shrink rappers for allowing viewpoints that don't agree with theirs without censorship. That is quite rare on the blogosphere and is much appreciated.

Having said that, I am perplexed at some of Dinah's points. Even before Duane and Rob ever showed up on this blog, I sensed quite a bit of defensiveness about posts that raised some issues in psychiatry even when they were quite civil. I was getting the message, "hear no evil, speak no evil" even if that wasn't your intention.

In my opinion, you have tried to turn this into an issue of pro psychiatry vs. antipsychiatry when then are many gray areas involved. I pointed out that pro psychiatry people who are in the mental health system are scared to death to seek treatment thanks to the new commitment laws in our state even when in crisis. That is very serious and frankly, I am disappointed that no psychiatrist has responded.

I know you can't say too much on a comment by someone like me but surely, you are aware in general that having this type of legislation can scare away people who need help but fear being swept into the system involuntarily. How do you reassure them that this won't happen?

My point is that in the past, I have raised what I felt were thought provoking issues like this only to be ignored.

Regarding Rob's positions, I know what I am about to say won't be popular but frankly, I find them refreshing. I was beginning to wonder if any medical professional on this earth gave a darn about the erosion of civil liberties in mental health. Reading Rob's posts greatly encouraged me that one person at least cares and will fight for what is right.

Finally, this comment from Dinah:

""I find the vehement discussions against medications as being insulting to those who find them helpful and want to take them. Psychiatry is about more than a prescription pad.""

Once again, I am totally perplexed and feel proves that this issue is more than just about Duane and Robb.

If I remember correctly, a few commentators were adamant that they did better off of medications vs. being on them. They were only talking about their own experiences and said nothing against folks who were taking meds. Therefore, I am unclear how this is insulting.

That would be like saying I am insulting junk food eaters because I state that junk food has a negative effect on me. That doesn't make sense.

Anyway, I do agree that we all need to be civil no matter what.

AA

Sarebear said...

AA, I don't think that statement by Dinah about medications is odd at all, given how strongly non-medication routes to recovery have been repeatedly and excessively advertised; I'm not against exploring or even trying such avenues if one feels that would be best for them, and I'm not against (nor do I think Dinah is) against letting people know about such things, if you aren't constantly shouting it from the rooftops every chance you get. It seems a bit excessive to me to constantly promote such things. Then it is at least strongly implied if not outright said that psychiatry is bunk, in essence. When that sort of thing is stated right next to a whole host of non-medication recovery options, or at least by the same person, the negative attitude(s) about psychiatrists and their use of medications in any kind of treatment seems clear to me.

jesse said...

Leslie wrote, " I don't agree with that law and would like to see it change to prohibit involuntary hospitalization of people who are oriented and who have committed no crime."

So here was the last situation in which I involuntarily hospitalized someone, over 25 years ago: I was called to an apartment by the building superintendent. My patient had been hearing voices, thought that the devil was sending signals to control him that were coming out of the electric wall sockets, so he pried off the covers with a screwdriver and was trying to stop the devil by pulling out the live electric wires with his bare hands (read this again, it's true that he did this). Apartment a total wreck. He disheveled. Not suicidal. Not threatening anyone. No laws broken. We all (parents, super, and me) were scared to death of what this could lead to.

I went to the police station and signed an emergency petition for him to be brought to a hospital.

What would you have done in my place? And, imagine no psychiatrist had been there. What would the super have done, and what would the police have done if left to draw their own conclusions?

One point I am making is that, even without psychiatrists, people will take action that might be far worse for the patient than what a psychiatrist might do.

I hope this is addressing some of AAs questions. They are good questions and should not be ignored.

jesse said...

P.S. You might say, "But he was a danger to others! He was a threat to others!" But does not this conclusion require interpreting what was going on? It requires some judgment. Who should make that judgment? The current laws allow a two physicians to do so, reviewed later by a judge. What would be a better solution?

Rob Lindeman said...

"What would be a better solution?"

Leaving him alone

Dinah said...

Thank you, everyone, for a more civil tone. It's much easier to read and consider your viewpoints and to have a discussion this way.

Passion is fine. Dissenting viewpoints are fine. My objection was with the delivery, so thank you all for the responses.

AA: I have absolutely no problem with "Medicines hurt me" or "I do better off medicines." It's when it turns in to "Medicines hurt me so no one should be on them" that I feel it's insulting, and even then, if the delivery is not hostile, mean, or judgmental, even that seems fine. I may not agree, but that's okay. Any shot you have a twinkie you could donate to me?

Anonymous said...

I just found this article, http://www.msnbc.msn.com/id/41002034/ns/slate_com/, Mental illness' not an explanation for violence

An exert:

"Shortly after Jared Lee Loughner had been identified as the alleged shooter of Arizona Rep. Gabrielle Giffords, online sleuths turned up pages of rambling text and videos he had created. A wave of amateur diagnoses soon followed, most of which concluded that Loughner was not so much a political extremist as a man suffering from "paranoid schizophrenia."

For many, the investigation will stop there. No need to explore personal motives, out-of-control grievances or distorted political anger. The mere mention of mental illness is explanation enough. This presumed link between psychiatric disorders and violence has become so entrenched in the public consciousness that the entire weight of the medical evidence is unable to shift it. Severe mental illness, on its own, is not an explanation for violence, but don't expect to hear that from the media in the coming weeks.

Seena Fazel is an Oxford University psychiatrist who has led the most extensive scientific studies to date of the links between violence and two of the most serious psychiatric diagnoses—schizophrenia and bipolar disorder, either of which can lead to delusions, hallucinations, or some other loss of contact with reality. Rather than looking at individual cases, or even single studies, Fazel's team analyzed all the scientific findings they could find. As a result, they can say with confidence that psychiatric diagnoses tell us next to nothing about someone's propensity or motive for violence."

Of course, it is easier to just deprive people of liberties instead of taking a look at the facts. Sigh!

AA