Sunday, July 03, 2011

Beards & Bow Ties

I stole this from Dr. Shock. It was written, directed, and narrated by Kamran Ahmed (no, not the Bollywood star -- the UK psychiatrist).
Seems like as good a time as any to turn on comment moderation.  Pretend you're in our living room.

And do join Clink in a discussion of tonight's CNN piece on St. Elizabeth's Hospital and the insanity defense.


Anonymous said...

I love this video. I am someone (now 26), who was not adequately helped by psychiatry as a teenager suffering from the effects of long-term domestic abuse by a severely alcoholic father and a mother who was too passive to help.

This does not keep me from having faith in psychiatry. Indeed, I had some wonderful psychiatrists who were compassionate and constantly striving to find creative solutions to some of the problems I faced.

Sometimes I feel the danger can be in viewing a patient through a particular lens - in my case, through the bipolar lens. I had a few residents and fellows who were looking at things in not quite the right way. So the medications I received were not always appropriate to the diagnosis (PTSD), and I sometimes felt consigned to a category that didn't feel right.

Here is what psychiatry did for me: it gave me exposure to people who were doing the hard front-line work of dealing with incredible sadness, pain, and anger. These people were asked to resolve multifaceted problems for which the science of cure was (and is) still in its infancy. But they ALWAYS KEEP TRYING.

I returned to psychiatry three years ago while working through therapy to address the longstanding PTSD. My psychiatrist was very helpful in prescribing prazosin for my nightmares. When I was amazed at its effects and asked her why it wasn't more widely studied, she said it was because there was no money in it. Psychiatrists are caught between wanting to help people and being perceived as drug pushers egged on by pharmaceutical companies. Even their tools are questioned. This psychiatrist knew of a drug that was truly helpful that companies had no interest in because it was cheap and widely prescribed as an anti-hypertensive. She prescribed it regularly anyway.

So although I felt misdiagnosed as a teenager, I never felt maligned or neglected or controlled. The psychiatrists I have seen were always nobly making an effort to make a difference against great odds. Unlike instant-gratification specialties like surgery, psychiatry relies on relationships and long-term change. This requires persistence, creativity, sensitivity, and optimism.

Thanks, psychiatry. You've enabled me to move forward. You've facilitated life-saving therapy. You have made a difference in my life - not because you are a cure-all, but because you helped enable me to help myself.

jesse said...

The psychiatric community is truly world wide. The cartoon is both entertaining and accurate ("quite brilliant!" as they say). Dr. van den Broek from Holland, Dr. Kamran Ahmed from London, and the same problems with our specialty we see here. No mention of insurance reimbursement, though...

One inaccuracy: the drawing of the psychiatrist's beard should have shown a Freudian beard, but, actually, Lucian Freud is now more famous in the UK than his grandfather!

Steven Plunkett's animation brings it alive, and Dr. Ahmed narrates very professionally. Kudos!

Sarebear said...

Very timely, very interesting, with a laugh here and there, and more serious points as well.

Thanks for posting this!

rob lindeman said...

Nicely done as a recruitment video, but failed to convince on two occasions.

The narrator insists that psychiatrists do not involuntarily treat and commit people "lightly". I never doubted this. The problem is not the gravity with which the decision is taken, but that involuntary commitment and treatment happen at all.

The second was his plea that people would accept psychiatry when we collectively accepted that mental illness is the same as biological illness. I insist that it's possible, indeed necessary to treat mentally people with love and compassion without making the equation (mental illness = biological illness, (like diabetes!). Most people understand conceptually grasp metaphor, even if they have never defined the term.

I know devout Catholics who understand that the Eucharist service, in which bread and wine become the blood and body of Christ, is a literalized metaphor (though it's impolite to say so). They nevertheless remain devout Catholics.

wv = sweica. Fourth generation artificial sweetner. This one's not carcinogenic. Really, it's not!


katie said...

I loved this. Psychiatry is an amazing profession, with the capability of so much healing. Like any profession, psychiatry has good practitioners and bad. I guess the difference with psychiatry is that if you come across a bad practitioner, most people, other therapists included, will encourage you to stick it out (barring blatant misconduct, such as sexual activity). If you come across a bad surgeon, most people would encourage to get a second opinion. Perhaps that's due to the stigma accorded to people seeking help for mental illness, I don't know.

(Good) psychiatry and (the right) medication saved my life. On the other hand, (Bad) psychiatry and (the wrong medication) made it an unlivable hell. I don't forget either part.

Sunny CA said...

I enjoyed it a lot and had an extra laugh because my psychiatrist wears a bow tie and has a beard!

Maggie said...

Rob, you keep saying "involuntary treatment should never happen." I haven't seen you suggest what should happen instead.
So say somebody is convinced they have to kill their mother because she's collaborating with the CIA to steal their thoughts. What should happen? Just wait until he tries it, and pray that the mother survives, then prosecute him for either murder or attempted murder, depending on the outcome? She could be warned, but that alone doesn't guarantee her safety. Arrest him for making threats?
What if somebody is too incoherent not to wander out into traffic? Just wait until they get killed and/or cause major traffic accidents that kill other people? Wait until somebody gets killed when they hit a pole after swerving to avoid hitting the person in the middle of the road?
Or should anybody with mental illness just be isolated from the rest of society, so that those decisions would never have to happen? Send them to some island somewhere? Would you consider that a better solution?
You repeat the same things over and over again, taking any excuse to insult psychiatry while conveniently ignoring all of the things that make your arguments nonsensical.

I find the comparison to diabetes incredibly ironic, given that diabetic emergencies make up so many of the 911 calls for altered mental status. Granted, by the time they're about halfway to the hospital some of the glucose they've been spitting all over the ambulance has actually gotten into their bloodstream and they start making sense again, so witnesses are usually limited to the ambulance crew, whoever made the call in the first place, and maybe a state trooper or two if they got particularly violent. I guess that makes it easier to ignore just how similar diabetes can be to mental illness.

moomag said...


Dinah said...

Oh,no-- I finally did leave a comment without passing it in to the post, and it was Maggie's comment.

In it, she notes that Rob keeps saying that involuntary commitment should never occur, and she points out that he never gives alternatives. There are some examples, given in the form of questions.

I left the comment in the moderate box for my co-bloggers to decide, but my feeling is that questions asked in a provocative way comes off as a personal attack. I agreed with Maggie, and I've wondered the same thing about what Rob and Leslie think should happen, but since I've been rather preachy about 'delivery' I decided to leave this one off the blog.

Dinah said...

Hmmm, well I guess Roy or Clink thought Maggie's post wasn't too provocative.

Maggie said...

In my defense, the irony of the diabetes analogy part of my comment wasn't really directed at Rob. His comment reminded me of why I think it's such a comical comparison, but it was a seperate thought from the rest of my comment.

Anonymous said...

Regarding what should happen to the confabulated person who is threatening to kill his/her mother. I'm sure the laws differ by state, but I would imagine that it is illegal in most if not all of them to make a threat to kill another person. I will speak about Texas law since that's the only thing I'm familiar with. In Texas, it is my understanding that if a person threatens to kill someone they can be arrested for making a terroristic threat and probably also charged with harrassment. So no, you do not have to wait until a person kills someone to intervene. I would not support forced medication, however.

The diabetes comparison does not work for me. If patients with mental illness were treated with the same dignity once admitted, then I might believe it, but unfortunately patients who are involuntarily admitted are often treated like criminals. Can you imagine a nurse yelling at a diabetic for stepping over the black tape in front of the nurse's station or yanking the phone out of the wall while a patient is talking because it's group time? Of course not.


Roy said...

I thought she made good points and was respectful to Rob. While I agree with her points about him ducking the hard questions, I am willing to remove it if Rob feels attacked. (I'm feelin' the irony, Maggie; you don't even need to say it ;-)

Roy said...

I've had this come up in Maryland, where I learned some years ago that police would not do anything about a threat to kill someone unless it was an elected official or the threat was conveyed via a telephone or via U.S. mail. There must be more subtleties to this.

Anonymous said...

Roy, it may be the same in Texas in that it would seem that the accusor would need to have proof of the threat before someone is incarcerated. Otherwise, any disgruntled family member could make up a story and have the family member or friend hauled in against their will based on some made up accusation. We don't want that.

wv = persin. Despite my various psychiatric diagnoses, I have always been oriented to persin, place, time, and situation. :-)


Maggie said...

Leslie, I believe (somebody please correct me if I'm wrong) that it's already been established (on Shrink Rap, anyway) that psych patients shouldn't be treated as sub-human. I know that when I'm speaking of a hypothetical "what should be," it's just that: what should be. If it's that someone needs help, I don't mean that they should be belittled and abused, I just mean that they should be helped. I have been under the impression (again, somebody correct me if I'm wrong) that most of the objections to involuntary treatment are objections to bad treatment. I don't believe that anybody here is deliberately advocating for crummy treatment, and I believe only a few are actively arguing against helping somebody who needs help. The snag is when "help" turns out to be harmful.

I expect that at some point in the future, psychiatry will be more objective and more concrete, and that treatments will be more likely to help the underlying problem. Somewhere down the line, it will have to be possible to test for specific problems with neurotransmitters, or scan for specific abnormalities, so that psychiatric treatment will be less about controlling behaviors and more about correcting objective problems.
The point to that speculation being, if/when we reach a point at which involuntary psychiatric treatment actually can treat a problem, wouldn't that be a better option than simply arresting somebody with a delusion that's convinced them they have to harm somebody?

I would consider involuntary help and involuntary harmful "treatment" to be seperate (but related) issues.
If we could know that a particular medication could cause somebody to regain their ability to think straight in the same way that we know that giving glucose to a diabetic with a blood sugar of 30 will cause them to start making sense again, wouldn't that change an awful lot?

Anonymous said...

Maggie, I agree that some of the objection to involuntary treatment is due to bad treatment, but I do believe it goes beyond that (although I didn't say so earlier). I think some of it has to do with the fact that we all have different ideas about what is helpful and what isn't. Even in the hospital I was in that was later shut down, there were patients who didn't want to leave. Some would want to be medicated if they were the confabulated patient in your example, while I and others would not.

I do think patients with mental illness should be treated just like patients with diabetes. It would help things a lot, I think. (I think the comparison probably works better in outpatient care which I believe is generally respectful). Oriented patients should always get to make their own decisions, even bad decisions. A diabetic who is oriented would not be forced to take insulin, yet an oriented patient with mental illness can be forced into a hospital. I would love for that not to be the case.

Unfortunately, the laws are what they are so I have to live with it. I'll have to settle on being relieved we cannot really fund AOT in this state.

I'm blathering (but hopefully I'm blathering respectfully).


Maggie said...

Leslie, I wouldn't have said you were "blathering." You're not going on half as much as I am. ;)

It sounds like there's a lot of variation state-to-state so far as criteria for involuntary holds and treatment. A lot of people keep expressing anger at how easily involuntary hospitalizations and treatments can happen, while the Shrink Rappers seem to be scratching their heads going "What?! On what planet can THAT be done?" They may not be accounting for the dishonesty of some professionals, but it still seems that the extent to which treatment can be forced is very variable by location.

Not to be a pedantic geek (oh heck, why do I bother to say that, when I know perfectly well I'm always a pedantic geek?) but insulin lowers blood sugar. High blood sugar generally causes chronic damage rather than emergency situations. It's hypoglycemia that usually brings about diabetic emergencies, they need glucose, not insulin.

But anyways, back to my hypothetical scenarios. You didn't seem to disagree with involuntary treatment of someone too disoriented to make a decision at all, so I'm not clear on which of my scenarios you're referring to when you say that you wouldn't want to be medicated. Or whether you were speaking of current maybe-they-work-and-maybe-they-don't-and-usually-have-nasty-side-effects medications vs. a theoretical future medication that would be more targeted to a specific known problem. Or were you referring to my theoretical future in which there would be more solid scientific knowledge so far as psychiatric illness?
I'll certainly grant that, at some point between now and that theoretical future, the difference between illness and simple variation would have to be solidly defined. (I mentioned it before when Sunny CA asked for book suggestions, but didn't say much about it at the time-- C.S Friedman's This Alien Shore is a great book that while not strictly about that, takes place in a future that has dealt with the issue in several interesting ways. And there are plenty of cheaper-than-dirt used copies on Amazon. [And here's where I bite my tongue to avoid ranting about the price of dirt.])

Some issues are situational, but at least some have to have a physiological basis, right? The way many psychiatric patients are treated currently can only be described as cruel; but if we reach a point in the future where a physiological basis for a disorder can be known and corrected -- if we could know for sure that someone is so miserable that they want to die because of a specific imbalance or deficiency that was completly treatable -- wouldn't it be cruel not to give it to them? Even if they were so hopeless at the time that they couldn't imagine the possibility of ever feeling better? I object to drugging people up to keep them quiet and easily controlled, but what if there were real solutions?
I'm imagining that in this hypothetical future, an advance directive could be written made a considered decision that they didn't want treatment, in order to distinguish who has made that decision and who might feel that way only when extremely depressed (or manic, delusional, etc.) Is it fair to hold somebody to a decision made, not by consideration of options, but just out of hopelessness?

(I hope I'm not getting too abstract with this to make sense.)

Roy said...

Leslie, I agree with many of your points above, though I would change the litmus test for deciding if a person can make their own good or bad decisions from a simple "are they oriented?" (meaning aware of person, place, and time) to "are they able to make an informed decision?" (meaning they can CRAM: Communicate consistent decisions, aware of Relevant facts, able to Appreciate the situation/consequences of agreeing or refusing, and able to Manipulate the necessary information to arrive at a decision).

The reference for this is Huffman & Stern, 2003.

Maggie said...

Roy, I like those criteria, but there's one little problem. "Inability to communicate consistent decisions, use relevant facts, or appreciate the situation and consequences, and lack of ability to manipulate the necessary information to arrive at a decision" sounds like a perfect description of quite a few of the most popular politicians.

..So just who would be implementing this policy?

(I do intend this comment to get a laugh.. But the kind of laugh that goes along with a *facepalm*. The fact that it's so very true scares the heck out of me.)

Anonymous said...

Sorry, Maggie. I think my glucose might have been a little low yesterday when I wrote my post. There was a disconnect between my thoughts and my typing fingers.

When I was talking about not forcing insulin on a diabetic I was thinking of a scenario where a hospitalized patient with uncontrolled diabetes kept a bag of candy at bedside. Glucose kept running >400. Diabetic educator was called in, endocrinology consult obtained, diabetic diet ordered. Patient kept consuming gobs of candy despite the education and recommendations. Patient was not forced to do anything she didn't want to do, staff did not march in and snatch her candy away or force insulin. She was allowed to refuse treatment even though she was self destructive.

However, my example is not equivalent to your example of hypoglycemia as the patient in my example with hyperglycemia was oriented. So, back to your example where the patient was disoriented due to low blood glucose. If the patient is oriented enough to know who they are, where they are, and what year it is, they are oriented enough and would be allowed to refuse the glucose (unless they happen to be in a psych ward where being oriented unfortunately isn't enough).


Anonymous said...

Roy, in practice patients are generally allowed to agree to treatment or refuse treatment if they are oriented (unless someone comes along and decides they are a threat to self or others). I agree that informed consent is more than simply being oriented. It also requires that patients are able to understand the risks, benefits and alternatives to treatment. The patient's decision to agree (or not) to treatment be done voluntarily and not under threat. But again, in practice if a patient can answer the person, place, and time questions they are generally assumed to be capable of understanding teh risks, benefits and alternatives to treatment.

What I don't like about CRAM is that it's interpretation seems to vary based on the world view of the person in authority when it comes to psychiatric patients. For example, you mention patients must be able to communicate consistent decisions. What does that mean? Does that mean patients cannot consent to something and then change their minds?

The biggest problem I see is with the statement patients must be "able to appreciate the situation/consequences of agreeing/refusing." For example, if a psychiatric patient is noncompliant there is a tendency for folks to blame noncompliance on anosognosia. Surely if the patient was well, she would understand that what she needs when ill is medication and/or inpatient care or whatever else. Since she doesn't agree, it's proof she's too ill to make a decision.

Again, I understand that the laws are what they are and allow for oriented patients who are deemed a risk to self or others to be involuntarily hospitalized. I don't agree with the law, but it is what it is so there are certain thoughts patients will have to keep to themselves if they do not want to risk being hospitalized.

I agree the decisions to involuntarily treat a patient differ by state (due to differences in state laws and access to funding), and they can also vary widely from practitioner to practitioner. Case in point, the first therapist I saw had had multiple people hospitalized against their will. The next therapist I saw hasn't ever had anyone hospitalized against his/her will in > 30 years of practice. Same diagnoses, but differing world views between therapists regarding patient rights/autonomy.