Thursday, July 28, 2016

Murphy Bill --Now With Guns?

Pretend there's a photo of the U.S. Capitol here.  Blogger is not cooperating.

Let me first send you to Pete Earley's blog to read about the Murphy Bill, HR2646, which was passed by the House of Representatives with a vote of 422-2.  The Helping Families in Mental Health Crisis Act had bipartisian and broad support, but not until it was sanitized of it's controversial issues: patient advocacy groups remained funded, outpatient commitment was de-emphasized, and the right of a  patient with a psychiatric disorder to refuse release of their health information to family/caregivers remained intact (at least for now).

Honestly, as a psychiatrist I was perplexed that these things would hold up the bill.  Access to good -- or any-- psychiatric care is a huge issue in our country.  Civil rights are important, psychiatry has a history of abuses, and patients should have access to advocacy.  HIPAA rights and outpatient commitment pertain a few patients  and while these may be pressing issues in the lives of the parents of the sickest of the sick, they are issues that don't come up everyday for your average psychiatrist.  So was I pleased when the Act was sanitized of some of the more controversial issues and I've deemed the newest version of HR 2646 the Vegetarian Version : not enough meat for the carnivores and too much for the vegans.  And P.S., none of these issues were going to prevent mass shootings anyway.  I just hope that if the legislation goes through, it leads to meaningful change in access to good care for the patients.

So a vote of 422 to 2; It seems we have a pizza bill with bipartisian support and little opposition -- all but two vegans knocked off the cheese and voted in favor.  Surely, such a bill will pass in the Senate, but if you read Pete's blog post, you know that the bill has hit a wall because Senator John Coryn of Texas wants to tack on a gun issue to the legislation.  Pete has gone into the details of the gun legislation Coryn wants to add, and I won't, because really, does it matter?  It's a mental health care bill;  it's not a gun bill.  It's time to separate these issue, and it's not the time to throw a bunch of controversial pepperoni on legislation that  has finally gotten agreement after three years of debate.  

Can we go home now? Oh, wait, Congress left already.

Wednesday, July 27, 2016

Boy or Girl and Are You Sick?

First, let me send you to an article in the New York Times: W.H.O. Weighs Dropping Transgender Identity from List of Mental Disorders.

There are lines we've drawn in medicine: a fever above a certain degree is not normal and indicates a pathological process.  A tumor that will spread and debilitate you is not normal and indicates a pathological process.  To be pervasively sad, uninterested in the things you enjoy, and want to kill yourself is not normal and indicates a pathological process.  And to hear voices and believe that someone is monitoring you when no voice or stalker or agency is there, is not normal and indicates a pathological process.  

In psychiatry, the line gets blurry at times: to be sad, fatigued, and uninterested is normal if you're grieving.  And even with that tumor -- suddenly, as ClinkShrink will tell you -- there is this funny question of whether doctors should remove your tumor or just kill you with physician-assisted suicide.  In some cultures, those voices you hear, or those seizures you have,  may not indicate pathology but visitations from God that hold you not as ill, but as superhuman and special.  You prefer your intimacy with little boys?  In Ancient Greece, it may have been fine,  but in modern America, if you act on it you spend time in prison and get labeled, stigmatized, and restricted as a sex offender for life.  And homosexuality with a consenting adult-- who even notices anymore?  Unless of course you live in Saudi Arabia or a variety of other middle eastern countries where they just execute you.

When I was in training (oh, that was a while ago), Gender Identity Disorder was considered rare and pathological.  Even before that, I remember a lecture in my college Abnormal Psychology class.  The professor was Martin Seligman, well known for his book, Learned Helplessness, and in discussing gender disorders, he mentioned that he traveled a lot and when he woke up disoriented in strange hotel rooms he always knew two things: Where the bathroom was and that he was a man.  Okay.   It was his introduction to his lecture on disorder of gender: it's not normal and you're not supposed to feel like something you're not. I have no idea if Dr. Seligman's ideas have morphed with the decades.

In my clinical experience, it seems that gender identity issues came with a slew of distress.  People with these problems often have other issues as well: problems regulating their mood, self-injury, and a host of emotional and interpersonal issues.  Are these issues part and parcel of Gender Identity Disorder, or are they the result of societal disapproval?  If we just accept transgenderism (is that a word? It should be) as being perfectly normal --or at least not pathological -- would the distress that accompanies it just go away?  Can we create a world where people choose their gender, or where they lie along a spectrum of male-femaleness, and their parents and society are completely open to the idea that one can choose and this is fine?  At what age would we allow for hormonal treatments?  For irreversible surgeries?  Does health insurance pay for these treatments if it's not a disorder?  I have no answers for this, but I find it fascinating that illness --and criminality-- are things of flux that change in time and with culture.  Funny to grapple with in a world where we make such a big deal out of which bathroom you choose to use.

Sunday, July 10, 2016

News. News. And Too Much News.

Oh my, time has been getting away from me  and it's been a bit since I've written a blog post on Shrink Rap!  

First let me steer you over to Clinical Psychiatry News where ClinkShrink has written an article called "New Mexico High Court States that Assisted Suicide is not a Right."  If you surf over, you'll also note that Clink has a lovely new head shot up next to her article.

As I've mentioned before, the Boston Globe's famed spotlight team is doing a series on the trouble public mental health system in Massachusetts.  The second installation went up on July 7th and discusses the roll of the police, and police training, in handling psychiatric emergencies.  It read just a little like the chapter from our forthcoming book, Committed, only I liked our chapter on the police and Crisis Intervention Training much better (perhaps I'm biased?).  In writing our chapter, I was privileged to have the help of Montgomery County PD officer Scott Davis and he is a treasure.  Also, our chapter had more meat to it,  so you can check out the Globe's piece and when Committed is available, let me know which you like better.

Otherwise, I have to say that the news is leaving me rather despondent.  I tend to be an optimist, to have at least a little trust in the system and in the goodness of people, and it's all being tested.  341 million people in this country and we can't find two smart, honest, kind, capable and energetic people to run for president.  The stories of police officers shooting people leave me ill, and the mass murders in Orlando (which now seems to be old and forgotten news) and Dallas, are just horrific.  Baltimore has always been a dangerous city, and the Freddie Gray trials are wearing on us all.  There are protests, sink holes, random murders of children.  In the last two days, a former Hopkins professor was murdered while walking her dogs (the assailant remains at large) and a 21 year old young man in the suburbs was shot and killed while walking his girlfriend home.  Between the election and the crime, I may be due for a social media vacation.  I'm sad.  Can't we make America Kind Again?