Saturday, May 16, 2015

Shrink Rappers at the American Psychiatric Association's Annual Meeting in Toronto, May 2015

A
APA starts today and I'm updating the list of talks we'll be giving.  Roy is already in Toronto for the APA assembly.  We will  be doing the same talks as I had previously posted, but some of the other speakers in our symposia/workshops have had to cancel, so here is the updated schedule.  Any suggestions for restaurants or fun sights in Toronto will be much appreciated!


I'd like to invite you to come here us speak at this year's annual meeting in Toronto.

We will be speaking at the following symposia and workshops:

Value in Mental Healthcare: What Does It Mean, and Who Decides? - Symposium
 Toronto Convention Centre - South, Level 800, Room 801 A,  
 2:00 PM - 5:00 PM, Monday May 18th

Speakers:
Robert Roca, MD, MBA, MPH
  --Value: Medicine's Holy Grail
Benjamin Liptzin, MD
   --Value: Perspectives on Outcomes and Costs
Henry Harbin, MD
   --Measuring Outcomes Using Standardized Tools: Why It's    
      Important and How To do It
Dinah Miller, MD
 --Value: What Matters to the People We Treat?
Sunil Khushalani, MD
  -- Eliminate Waste, Improve Value
Steven Sharfstein, MD
   --Discussant 
-----------------------------------------------------------------------------
- Are You a Sitting Duck Online? What You Can (and Can't, or Shouldn't) Do About Negative Reviews Your Patients Post About You-Workshop

Toronto Convention Centre - South, Level 700, Room 711, 9:00 AM - 10:30 AM, Tuesday May 19, 2015;

SCHEDULED AGENDA

 Introduction to review sites: John Luo, MD
 Personal experience of negative review: Dinah Miller, MD
 Small group exercise
 Constructive responses by individual psychiatrists and the    
    psychiatric profession:  Paul Appelbaum, MD 
 Future directions: Laura Roberts, MD
 Q and A
_________________________________________________________________

Practical Privacy Issues 

Wed, 5/20: 11:00 AM  - 12:30 PM
11:00 A.M. Sessions

Metro Toronto Convention Centre -Level 800, South Building 

Room: Room 802 A-B 


Presenters:  

~Paul Appelbaum, M.D.,  NY State Psychiatric Institute 

~ Erik Vanderlip, M.D.,M.P.H. University of Washington

~Lori Simon, M.D.

~Steve Daviss, M.D.    FUSE Health Strategies LLC


Objectives:


  • List issues related to electronic health records and HIPAA and other laws and regulations and how to cope with them.
  • Describe how to avoid computer and technology operations that increase the risk of confidential data being stolen.
  • Take steps to limit risks of financial data being stolen apart from other steps to safeguard patient-specific sensitive data.
  • Describe how to use psychotherapy notes to maintain privacy. 
___________________________________
National Action Alliance for Suicide Prevention: Recommendations for Prevention From the Suicide Attempt Survivors Task Force Report--Symposium
 Toronto Convention Centre - South, Level 800, Room 803 A/B, 2:00 PM - 5:00 PM


ABSTRACT:
The stigma around suicide is often associated with whispers or silence, despite the fact that prevention of suicide is a national priority. The National Action Alliance for Suicide Prevention
convened a national task force of suicide attempt survivors last year, releasing a groundbreaking, federally funded report called The Way Forward. The goal of this report is to provide a framework for national, state, and local stakeholders to use when developing resources and initiatives to prevent suicide as part of the National Strategy for Suicide Prevention.
This groundbreaking report identified eight Core Values and seven Recommendations that are helping to catalyze major changes in the national approach to suicide prevention and response. The
speakers will discuss ways in which clinicians and others can bring the report's recommendations to life and open channels of communication and awareness around the topic of suicidal thinking.


Chair: Steven Daviss, MD
Discussant: Dinah Miller, MD

THE NATIONAL SUICIDE PREVENTION LIFELINE
: John Draper, Ph.D. : Project Director for the National Suicide Prevention Lifeline


LIVED EXPERTISE: INNOVATIVE PROGRAMS, INTERVENTIONS AND SUPPORTS FOR PEOPLE EXPERIENCING SUICIDAL INTENSITY INFORMED BY LIVED EXPERIENCE
Presenter: Eduardo Vega, MA




Finally, Dr. Hanson will not be presenting at APA, but she will be presenting at the American Academy of Psychiatry and the Law meetings in Toronto earlier in May.  We will post her schedule once it is finalized.   

Thursday, May 14, 2015

Per Twitter: Dear Dr. Lieberman and others.....


 Oh my. So over on my Twitter account, I tweeted a tweet that has now been favorited, retweeted, mentioned, ?distorted, and tagged such that I've received over 30 notifications on all sorts of stuff I'd rather have nothing to do with. 

So let me start the story at the beginning.  Earlier in May, the New York Times ran a column called This is My Brain on PMS.   It was a first person account of someone's mental anguish and emotional instability during the premenstrual time.  

Jeffrey Lieberman is a former APA president, the chairman of psychiatry at Columbia, and author of a new book on the history of psychiatry called "Shrinks."   Dr. Lieberman has previously tweeted sentiments that indicate that he wishes the NY Times would publish more science-oriented psychiatry articles and devote less precious space to these "opinionator" pieces or to anything with a sentiment that is critical of psychiatry, although I understand his book is rather critical of psychoanalytic practice.   It's hard to know what is in someone's heart in 140 characters, and Dr. Lieberman posted the following tweet:

I guess the introspections repeatedly published by do provide 1st person accts of disorders



Why is a patient's narrative of their difficulties 'narcissism'? . Perhaps public accounts are destigmatizing.







Tuesday, May 12, 2015

Writing about Patients -- or Not


CouchNovelist and psychoanalyst Lisa Gornick has an article in today's NYTime Opinionator, Why I Never Write About My Patients.  She talks about how she ended her career as a psychoanalyst when her novels became successful.  First a leave of absence, then the separation became a divorce.

Gornick writes:



During the years when my stories appeared only in obscure literary journals, never seen by any of my patients, the marriage between my occupations was comfortable. With the publicity that accompanied the publication of my first novel, in 2002, however, many patients became aware of my writing. I knew that whatever responses they might have were “grist” for the therapy mill, but I also knew that just as dreams are transformations of the unconscious of the dreamer, literary works plumb their authors’ inner lives. Analytically oriented therapists such as myself use our responses in sessions as a way of understanding our patients — in a sense, lending our unconscious for the purposes of the treatment. But adding my patients’ responses to my novel into the mix — having my characters, with their links to other corners of my unconscious, in the treatment room — risked, I feared, both clogging the therapeutic mill with too much grist and inhibiting my writing work out of concern for its impact on my patients.

I stopped taking new patients, gave my current patients 18 months notice (sufficient time for nearly all to complete their treatment) and commenced an extended leave.


Eight years later, I tested the waters for returning to my practice — only to discover that the separation should be a divorce. With many of my stories and essays and interviews now available online, and with new mores in which there is no hesitation about looking up anything about anyone, I felt too exposed.
 I'm not one for writing about my own patients, it just doesn't seem either necessary or right, so I can relate to Gornick's concerns.  But when it comes to the analytic belief that the psychoanalyst must be a blank slate whose personal life remains hidden from the patient, then I drift off.  Times have changed and it's hard to remain obscure.  I like social media, and the Internet makes us all so much more more exposed than we'd like to be.  It takes a rare person to ward off every activity that might show up online.  When I think about it, I feel smothered.  In the office, I'm mostly me, but modified to meet the needs of my patients.  In my free time, I'm all me and fortunately the 'me' who lets loose has no criminal convictions.  

Tuesday, April 28, 2015

Some thoughts on Authority and Victimization


This is our blog, and it's my place to vent some, and on this beautiful morning in Baltimore with all the trees in bloom in pink and white, I could really use some space to vent.  While none of us were in the middle of the unrest, it is awful to watch our beloved city on CNN -- this isn't how it should be.
I'm not going to write about riots or police brutality, but I do want to write a little about authority and  victimization, and for that I'm going to ask you to surf over to my friend Pete Earley's blog where he talks about a psychiatric patient who was arrested after biting a nurse in an Emergency Room.  And Pete is my friend, but I may not be gentle here, but I'll trust that he'll still be my friend even if we don't agree about everything.

Before I start, I want to make it clear: I oppose violence of all kinds by all people.  I strongly oppose police brutality, and I strongly oppose  throwing bricks at anyone or destroying businesses and property.  Let there be peace in Baltimore today and tonight and for all days to come. 

  #Black lives matter.  #Blue lives matter.  #Patient lives matter. #Nurses lives matter
 # All lives matter. 

So Mr. Earley wrote a post not long ago titled  We Took Our Daughter to the ER for Help. She Ended Up Being Arrested. 
     A parent writes in:
My daughter was then informed that she was going to be involuntarily hospitalized. She became even more agitated and when she threatened to leave, a nurse confronted her and a scuffle broke out. My daughter was forcibly restrained by five hospital personnel.
The nurse prepared an injection to calm her and my daughter, who was terrified, said: “’I’ll take the pill. I’m scared of needles.” The nurse proceeded to give her the shot anyway and my daughter would later tell us that she went black.
The nurse was pushing her elbow into my daughter’s chest and our daughter bit the nurse’s arm. She didn’t break the skin and there was no blood. 
Our daughter was put in restraints. Her arms and legs were all restrained, so tightly that her hands began turning purple. I thought things couldn’t get worse but they did. Two officers showed up at the ER to arrest my daughter for aggravated battery against the nurse.

The parent continues -- she's angry that the charges weren't diverted to a mental health court because the nurse wouldn't agree to this.  The parent is distressed and doesn't feel her daughter should be criminalized.

When you look at it, this post is rich with material on so many levels and there are so many things to take issue with.  I wasn't in the room, so I don't know if there wasn't some kinder and gentler way of dealing with this patient besides restraining her, injecting her, and escalating her fear and anger.  And really, if the story is accurate, then perhaps it would be reasonable for the patient to plead self-defense, or to press charges herself for the brutal treatment she received (I have no idea if a patient can do that).  Here, however is what Mr. Earley has to say:

"It is even tougher to understand why some victims insist on pursuing charges when the infraction seems so minor, as it appears to be in the case of the nurse who was bitten."

I, like Pete, believe that people in authority need to have special training in dealing with difficult populations and that people should not be unnecessarily provoked.   But we know nothing about the nurse besides the fact that she went to work, did her job (for better or for worse) and was bitten.  I don't know that the right answer here is to press charges, but I also know that it's not reasonable to tell people they need to go to a job every day where they must tolerate being assaulted without any recourse.  Perhaps the nurse had been assaulted numerous times -- mental health staff often are --  and this can lead to a traumatized staff.  I heard one story recently about a psych nurse whose eye was poked out by a new patient on a unit with no warning (~not in the course of restraining someone) by a patient who had a history of violent crimes.

I don't have an answer for this.  People get angry when they are mistreated, and as a society, we've become sympathetic to the victims of an aggressive authority and some people have decided that the resultant violent  response is understandable.    But the assumption is that the person in authority should be focused on doing the exact right thing, even if it means tolerating a work environment where they are in danger, often repeatedly, and that's just part of the deal.  The story above is told from the patient's perspective, not from the nurse's, and her side is dismissed for her lack of understanding and for insisting on pursuing charges for a minor infraction.  The assumption is that those in authority are somehow immune to the traumatization, fear, exhaustion, and if not, they should stay home or find another job.  And actually, perhaps someone who's sticking their elbow into a patient's chest should stay home, but then again, it's a third hand account and and we don't know the details of what transpired in the heat of the moment.

What's my point?  Simply that we're all human and perhaps these stories need to be heard from all sides before judgement is passed.  Perhaps if we could hear from the nurse, we might understand why she insisted on pressing charges, or perhaps we still might think this too extreme a response.  But it does nothing to encourage people to go into the field if you make the statement that they'll need to tolerate human biting without recourse.

Please don't read this as the idea that I'm condoning brutality by anyone.  I'm a huge proponent of kinder, gentler care, and I'm totally opposed to anyone biting nurses.  Some stories, however, lose something when you only hear one side. 



Monday, April 27, 2015

Involuntary Commitment and Suicide: Looking for Stories


As our regular readers know, we are working on a book called --at this moment in time-- Committed: The Battle Over Forced Psychiatric Care.  We're trying to focus on stories and as many people know, suicidal ideas and behaviors are one reason why people get committed.  I'm looking for one or two stories for our chapter about the experiences people have had with forced care and the spectrum of suicidality.  In particular, I'd like to hear from people who feel an involuntary admission helped them or a family member to get much needed treatment.  As always, however, I'll take what I can get.  Please feel free to comment below, or better, shoot me an email at shrinkrapblog at gmail dot com if you'd be willing to share your story in a book.  Obviously, we won't be using patient names or identifying information. 

Tuesday, April 21, 2015

The 29th Annual Mood Disorder Symposium at Johns Hopkins


Today I went to the 29th Annual Mood Disorders Symposium: Back to the Basics.  I somehow have missed the first 28, but this one was really excellent.  Let me give you the quick recap:

 
Karen Swartz, MD talked about "Reasons to Still Love Lithium."  The upshot-- it's very effective in treating and preventing manias and hospitalizations, and it has some anti-suicide properties that hold even for those people where it's not terribly effective as a mood stabilizer.  It works for depression as well.  You need to monitor kidney and thyroid function.  It doesn't work for everyone and everyone doesn't tolerate it.   And we're still learning how to best dose it.

Rosalyn Walker Steward, MD, MS, MBA talked about "The Recognition and Treatment of Depression in Primary Care Settings."  She discussed how most depression is treated in primary care settings and discussed the differential diagnosis for major depression versus grief/demoralization and how a primary care doc approaches diagnosis and treatment.

Lisa Townsend, PhD gave a quick introduction to "Dialectical Behavior Therapy: The Basics and Beyond."  She focused on the importance of recognizing and validating the patient's emotional experience.  

Mr. & Mrs. Jones talked about the patient's perspective of depression.  I have to say, I love when successful people talk about their struggles -- it does so much towards getting rid of stigma.  When psychiatrists and politicians talk about the need to decrease stigma...well, I find it a bit hollow.  So Mr. Jones is very articulate, and very successful despite his difficulties with major depression.

Kay Redfield Jamison, PhD gave a talk called "Writing a Life" and talked about the research she's doing for a book on poet Robert Lowell.  She always has interesting stuff to say.

And finally, poet/historian/atheist Jennifer Michael Hecht, PhD talked about the history of suicide and how she has been impacted by it.  

Some quotes I liked: 

Dr. Swartz: "If someone is taking lithium, you want them to be a partner with you in their treatment." 

Dr. Steward: "SIGECAPS"  Really, there's a mnemonic I'd never heard of?  To assess for major depression: Sleep/Interest/Guilt/Energy/Concentration/Appetite/Psychomotor changes/Suicidality.  It needs an "L" for Libido.  Or two "S's" for  Sex.  

Dr. Townsend: "Your response is understandable and real but it isn't getting you where you want to be." 

Dr. Jamison: "People get treated but they don't necessarily get healed."    It might have been worth the whole day for that one sentence.  

Dr. Hecht: "Poetry is the queen of places to expore new ideas."

Save the date for the 30th Annual Mood Disorders Symposia: 
April 19, 2016.
 
 

Thursday, April 09, 2015

Out of Network Care : Why?


I'm still thinking about what I'm going to say in my talk about value in psychiatry from the patients' perspective.
It seems to me that the question of value and getting one's money worth might include the fact that the cost is different in different settings.  So someone who gets care at a student mental health center, a VA facility, or a public clinic may well pay nothing.  And in private practice, many psychiatrists don't participate with insurance plans  and people may choose see a psychiatrist when they have no out-of-network insurance, and thereby assume a cost of hundreds of dollars per session.

So my question for now is quick, and again, it is meant only for people who have been patients.

Why do you see a psychiatrist who is not in your insurance network?  If this costs more than going with an in-network psychiatrist, what makes the extra cost worth it?

Wednesday, April 08, 2015

Do You Google Your Psychiatrist?



In psychoanalysis, one of the important principals is that they analyst is a so-called 'blank screen' for the patient to project his/her issues on for examination.  It requires that the psychiatrist remain a bit anonymous, and from this we have the tradition that the exchange of information goes one way in psychotherapy.  There are other, more bland reasons for this as well-- the therapy should be about the patient and the sessions should not be about the psychiatrist, and the doctor is entitled to  privacy.  Different psychiatrists address personal questions in different ways, and I'll tell you that most of the time, I just answer them. I'm neither a psychoanalyst nor a blank screen.

The New York Times opinionator section has an article called -- you guessed it -- Do you Google your shrink? which talks about how Google and the internet have changed the practice of psychiatry.  Blank screens are no longer an option, and Ana Fels writes:

I knew my psychiatric practice was forever changed the day a patient arrived with a manila folder stuffed with printouts and announced that it contained the contents of a Google search that he had done on me. He pulled out a photo of my mother and me, age 7, that had been published in my hometown newspaper; architectural plans for an addition to my house that was never built but apparently was registered locally by the architect; an announcement about my great-grandfather’s becoming editor of Amazing Stories magazine in his old age; and my brother’s history as a college activist.

People are funny in what they want to know.  One patient Googled me before our first meeting and found a review I'd written of a novel on Amazon.  She liked the novel, too, so she decided I must be okay.  Hiding isn't an option anymore.  And patients often know that I write.  I've had Shrink Rap quoted to me.  And the truth is that I am who I am, I can't live my life in hiding or give up writing, blogging, or tweeting because someone might learn something about me. 

So do you Google your shrink?  And what interesting things have you learned?

Tuesday, April 07, 2015

Responses to a Short Survey on Inpatient Psychiatry

147 responses

Summary

Was being treated on a psychiatric unit helpful to you?

Yes, I was better at discharge5738.8%
No, I was the same or worse at discharge9061.2%

Were you admitted as a voluntary or involuntary patient?

I entered as a voluntary patient and my stay was helpful3121.1%
I entered as a voluntary patient and my stay was NOT helpful4127.9%
I entered as an involuntary patient and my stay was helpful2919.7%
I entered as an involuntary patient and my stay was not helpful4631.3%

Was your treatment abusive in any way?

My treatment was kind and respectful to a degree I found reasonable and acceptable5336.1%
I felt I was physically abused by the staff1610.9%
I was verbally threatened by the staff4127.9%
I was treated by staff in a demeaning manner without an obvious reason8457.1%
I was assaulted by another patient96.1%
I was threatened by another patient2416.3%
I was physically uncomfortable because I was denied access to food or restroom facilities in a timely manner2114.3%
I was uncomfortable because I was not permitted to smoke.96.1%
Other4329.3%

Discharge

When I left, it was clear where I would go for follow up and when7853.1%
I left with no clear follow up appointment or plan4329.3%
Upon discharge, I was given prescriptions for medications I was able to obtain5336.1%
When I left I was given prescriptions for medications I could not afford117.5%
My prescriptions lasted until I had an outpatient appointment3221.8%
My prescriptions ran out before my outpatient appointment1610.9%
I never went to any followup1711.6%
I never filled my prescriptions138.8%
 
Comments:
 
i've been discharged to a safe house
I was released with the drugs
It's been 5 months since my hospitalization and I still haven't been able to meet with a case manager. It took 2 months for them to call me and they have rescheduled twice at the last minute.
price of prescriptions almost $400
Due to holidays and no case worker I didn't see anyone until about 6 weeks after discharge.
The meds were so costly, my entire prescription benefit for the year was used up for ONE month's handout, plus I had a $200 copay when I was told it was free (I told the discharge nurse these brand name antipsychotics were too costly, and she said no copay, but I was billed $200 later, and had to pay it)
The diagnosis was inconsistent with diagnosis of therapist and was based on false information from abusive spouse
they didn't set up where I was going of medication changes my regular out patient providers did
that made me worse than before I went in
I was very over medicated, against my instincts, and those instincts were correct once I got a second opinion. I was misdiagnosed with bipolar because I went manic on copious amounts of energy drinks- not because of a biological disorder. The drugs brought me down, but time/sleep during treatment would have done the same!
I only obtained a proper plan after a subsequent episode
I left when my own doc was appalled the treatment
Voluntary, private hospital, late 80s ( was 16), doubt I would have the same positive experience now.
I was already taking meds at the time.
Follow-up plan was poorly devised and seemed just to check boxes.
got out - tapered myself off all drugs - it took some time
One follow up told them was suicidal last I heard of them. Last attempt may of been successful. Hopefully yes but only time will tell and not going to the doctor to find out if I'm dying.
The Psychiatrist changed my perscirptions with disarterious results.
I was order to take oral and injection meds
I was asked to do an exit review but felt it would not be wise to honestly comment as i was worried i would be re-admitted at some point and they would have more ammunition against me.
Became an antipsychaitry activist
so my answer is irrelevant
Like whatever. Fix the damn system tired of losing friends to suicide. I love Billy btw. Loved your book too.
No one explained diagnosis.
I had no choice or options. I was violated.
They actually had me sign papers saying I was safe to leave the hospital when I told them I was no different if not worse ( signed papers with statement that I didn't agree but that I had seen the paper)
the drugs tranquilized for 14 hours straight when taken as prescribed; no information about tapering safely to a lower dose that I could function at was provided
followup prescribed inconsistent with their own diagnosis

What aspect of care was most helpful to you?

The medications1610.9%
The interactions I had with the psychiatrist117.5%
The interactions I had with the nurses42.7%
The interactions I had with other staff32%
The activities provided00%
The food00%
The physical environment42.7%
The interactions I had with other patients2517%
Group therapy and educational groups21.4%
The interactions I had with my family00%
The time I spent in a seclusion room21.4%
The time I spent in physical restraints00%
The opportunity to escape the stresses of my outside life (work, etc)2013.6%
Yoga, tai chi, massage, general healing00%
The coping skills I learned00%
ECT00%
TMS00%
Family visits64.1%
Support animals on the unit00%
Nothing at all was helpful3624.5%
Other1812.2%


Monday, March 30, 2015

What Adds Value to Mental Health Care? Looking for Your input....


I need  your help.  This year at the American Psychiatric Association's annual meeting in Toronto, I will be talking on what adds 'value' to mental health care from the patient perspective.  It's a symposium, and the other speakers will be approaching the issue from the perspective of the insurance company, the hospital, employers, and looking at things like quantifiable measurements of success measured with standardized tools and how to recognize waste in the systems.  I won't be talking about standardized tools.

So I need input.  If you're a  health professional and you've never seen a psychiatrist as a patient, please don't answer.  I want to hear what people see as 'value in mental health care' straight from a patient's perspective.  

Some possible questions include those below, but please feel free to tell me what you value about your mental health care.

  •  I'd like to hear what experiences and outcomes make you feel like you've gotten your money's worth?    
  • Why do you go to treatment?
  • What are you looking to get from it?
  • Do you have specific goals that you'd like to see measured by objective criteria?
  • Have you ever seen a psychiatrist for treatment, gotten better from your disorder, and yet not valued the care? Why?
  • Do you like that insurers and providers are looking at what makes for good value, meaning the best outcomes for the lowest cost?
  • In short: what makes for a good experience with a psychiatrist?  You can also tell me what makes for a bad experience.
  • While I've got you here, do you value having your psychiatric chart in an electronic medical record?

If you don't want to comment here, please feel free to email me at shrinkrapblog at gmail dot com.  

Sunday, March 29, 2015

"Mental illness" is not the Endpoint Answer to Why Someone Commits Mass Murder



Over on Clinical Psychiatry News, I wrote a an article about still-unfolding story of the Germanwings co-pilot who deliberately crashed a plane into the French Alps, killing 150 people.  Please surf over to read Was Mental Illness a Factor is the Germanwings Crash.   I'll warn you that the facts aren't all in yet, so the article is purely speculative, and it's possible we will never know why this co-pilot decided to crash this plane into a mountain.  I also tell you that as a psychiatrist, I don't know why someone commits mass murder; I've had no experience with patients who kill, much less kill 149 other people, nor have any of my colleagues or mentors.

Tawnydog1 may be right in her tweet above, the New York Times already has a front page article calling for  screening for pilot mental health issues.   Since the event of pilots crashing their planes into mountains is extremely rare (1 in many millions) and the pilot was said to have had an eye problem, I'm wondering why they aren't calling for better screening for eye problems?  Really, we don't know anything yet: we've heard nothing about the stresses in this man's life, whether he was telling friends and family that he was having delusions, why he took time off from training, what his illnesses were, and how he dealt with anger.  

I'm going to go out on a limb here: people commit suicide for a number of reasons, one of them being a way to escape the unbearable pain of depression.  People kill for a number of reasons, one of them being because they are angry.  There are many mentally ill people in the world and there are many angry people in the world.  There are very few mass murderers.  We need to stop using "mental illness" as the endpoint to answer the question "Why?" when a mass murder happens.  Mental illness is not an explanation, and this may be a problem that is so rare that there will never be a reasonable response to this event other than to say that for any number of reasons, pilots should not be alone in the cockpit of a commercial passenger plane.

Saturday, March 28, 2015

Resilience: Two Sisters, Mental Illness, A Trust Fun and Quite the Ride



Resilience: Two Sisters and a Story of Mental Illness is a memoir written by Jessie Close with journalist/advocate Pete Earley, plus a few 'chime in' chapters written by Jessie's actress sister, Glenn Close.  

So let's start with family history.  It's a good place to start and we learn that the Close sisters come from a line of those who were rich, famous and colorful -- ancestors with names like E.F. Hutton and C.W. Post.  Not to mention great-uncle Seymour who thought he was a German spy then took hostages at gunpoint and had his chauffeur drive them home.  

Close describes a happy childhood living on her grandparents' estate in Greenwich while her father remained in Manhattan for his surgery residency.  Happy, until her parents joined the Moral Re-Armament or MRA, a religious cult.  From there, the family began to fracture.  First, it was just the parents who left and MRA nannies raised the children,  but then the family moved to MRA-run estates in New York, then Switzerland, and finally Jessie -- the designated problem child-- joined her parents in Africa.  She describes a lonely, chaotic childhood marred by anxiety and abandonment. 

From here I'll avoid plot spoilers and just tell you that what follows is a story of sex (and more sex), drugs, alcohol, as well as some rock & roll with much of the compulsive energy being explained by either mania or depression.  There are five marriages and three children, countless houses, cars, and dogs,  and a diagnosis of bipolar disorder along the way.  Jessie eventually lands in a place where she is more comfortable, balanced, and in control of her emotions and behavior. 

Psychic peace, in this case, comes at a price.  Recovery is not a smooth road for Jessie and in giving up her mood swings, my sense was that Jessie lost a part of herself.  So if you worried that this would be a placating story of how psychiatry is all good, rest assured that the author has her share of rare adverse reactions to psychotropic medications, not to mention a struggle with medication-induced weight gain which she minimizes.  In the end, she finds solace in her own company -- something she seemed to find unbearable before -- and decides that she needs to forsake romantic relationships.  These tradeoffs are those a person will  make only when their pain is unbearable.  

The bottom line on the memoir: two thumbs up.  The book is a quick read as Jessie Close pulls you on to her roller coaster ride of a life with severe, unremitting mood swings.   

Sunday, March 15, 2015

How Was Your Stay in a Psychiatric Hospital? -- Please Take My Survey: 5 quick questions


I'd like to tell you something.  The comments we get on this blog, especially lately,  talk about how horrible it is to be treated in a psych unit.  People say they would rather die then go back, they're infantilized, demeaned, and sometimes people describe frank abuse. They deem it comparable to rape and torture.  In my all-voluntary outpatient practice, I treat patients who sometimes get hospitalized and I make a point of asking people about their experiences.  People end up in psych hospitals during miserable periods in their lives, so it's never a happy issue, but unlike our blog commenters, my patients often say the  hospitalization was helpful, that people were kind to them, and that they left in a better state.  I don't work in the hospital and I generally have open and warm relationships with my outpatients -- who know I don't have anything to do with inpatient units -- so I'm thinking that perhaps they aren't lying out of fear of retribution if they are readmitted.

Let me add something else, the two biggest psych units near me are rated in the top ten in the country.  This may well be a skewed sample.  Few people go to state hospitals in Maryland for routine psych care-- the state hospitals are mostly for forensic patients and the state leases out short-term beds in community hospitals for the uninsured.  There are still a few long-term patients in the state hospitals, but not a lot.  And the chairman of my residency program made a point of asking every patient he interviewed if they were being treated well; The patient might be afraid to say they were treated meanly by a nurse, but the nurse would be even more afraid.  And please don't think that means that no one ever muttered an insensitive word to a patient or did the wrong thing, but I do think most patients there thought it fell short of torture.  In urban areas, many are looking for "three hots and a cot" and the hospital often fills that roll.  And some of the units attracted patients from all over the country who really, really wanted to be there for relief of their torment.

I'd like to know about your experience if you've ever been treated as an inpatient on a psych unit.  Will you take a quick survey for me?  And please -- this isn't science,  it's not validated -- but please just answer one time and one time only. And thank you so much!


Thursday, March 12, 2015

How Psychiatrists Spend Their Time and Why the Agency Demands Contribute to the Shrink Shortage


Over on Clinical Psychiatry News this week, I wrote an article called Addressing the Psychiatrist Shortage: What Keeps us from seeing More Patients?.  Please check it out and tell me what you think. 

Tuesday, March 10, 2015

Responding to the reaction to Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations? Polarized responses!

I saw the Mad in America article about my post on

Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations?

 I feel like it was misrepresentative to say that I wanted to give people cake and ice cream, as if that would undo the violation people might feel, especially after involuntary hospitalizations.  I was drawing on the example of what I saw in mental health court, that people who were incarcerated as criminals, then chose to participate in the MHC with all it's requirements (generally many: treatment, medications, often substance abuse treatment, requirements for day and residential programs) yet  end with a sense of being proud.  There is a graduation ceremony and they come if they want, invite their families, get certificates, take photos with the judges.  No one is forced to come, and the have fried chicken --which I somehow found humorous, but at the moment it's looking a lot better than the cake and pizza which are my favorite cheap foods.  Readers felt was demeaning and comparable to birthday party food for small children, and if I ever suggest food again for any event, it may be lobster.  I was trying to say that if something presumably traumatizing -- like getting arrested and labeled a criminal -- could later be turned to something that wasn't so shameful, maybe we should consider that sort of thing to help people feel less traumatized and shamed with hospitalization.  Without the mention of Mental Health Court's approach, it comes off as sounding like I want to feed people cake to make their pain go away and undo the violations they were subjected to, which I never meant.  I wanted just to ask if people felt that some validation of their distress would be helpful, and I think people like food with events. Or at least I like food with events.

I realize that some people who are involuntarily hospitalized are terribly traumatized, which is why I'm writing the book.  I don't think psychiatrists see that and I think if it were figured it into the equation, maybe less people would be involuntarily hospitalized (certainly, no one should be forcibly hospitalized for 'sadness' as one of the MIA commenters put it), other alternatives could be found, and more of an effort would be made to treat those where there are no options but involuntarily hospitalized with respect and kindness.  I thought the responses were polarizing, while commenters here and at Mad in America complained that I was lacking empathy, defensive, and just plain evil, Psychiatric Times deemed it one of the top 6 articles on psychiatry for the month! 

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at: http://www.psychiatrictimes.com/cultural-psychiatry/monthly-roundup-top-6-psychiatry-articles-february?cid=tw#sthash.VQvM5YjA.dpuf

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at: http://www.psychiatrictimes.com/cultural-psychiatry/monthly-roundup-top-6-psychiatry-articles-february?cid=tw#sthash.8fBy2dv3.dpuf

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at: http://www.psychiatrictimes.com/cultural-psychiatry/monthly-roundup-top-6-psychiatry-articles-february?cid=tw#sthash.VQvM5YjA.dpuf
I stopped publishing the comments on my own blog, because as horrible as I hear people can be treated during involuntary stays, these feelings are not the same for everyone, and the comments because insistent, repetitive, and I don't think they left room for anyone to voice another opinion .  Some people get better and appreciate being in the hospital, some get better and still understandably resent it, and some are just terribly distressed for years.  When they get too extreme, I worry that people stop listening -- so while I know people feel terribly violated, I wonder if it wouldn't upset the victims of war torture, rape, and kidnapping, to have their experience compared to being in the hospital where people presumably are at least trying to help them?  And I think some people shut down when they hear someone compare treatment to torture -- there are those who will stop listening and discount their opinions. We live in a democracy, and I think folks might get more traction by talking with their legislators and proposing new laws; it's more powerful then blog comments.  And most psych hospitalizations are voluntary -- some coerced, but many people ask to be in the hospital, repeatedly, and find it helpful.

  I'm sorry this blog post turned out to be so polarizing.  No one has ever called me "evil" before.  And one commenter on my blog (unpublished) insisted psychiatrists just need to admit that their work is useless and never helps anyone and that I should become a gardener.  If it doesn't help you (and I mean the metaphorical 'you', not you personally!) then I can see why you might think that, but it seems unfair to insist that everyone has the exact same reaction to being hospitalized, or even being offered outpatient psychotherapy on a voluntary basis.   I'm also sorry that some of my comments came off as being defensive. Often I'm responding to blog comments quickly, between activities, and I often don't measure every word or consider how they might be construed from a variety of different perspectives.  Anyone who regularly reads my blog knows that my posts are done quickly and often with typos, I'm just stretched a bit too thin to do the proof-reading to catch them, and in a similar way, I sometimes reply to comments without thinking through every angle.  I also often have completely different views than the commenters.  And I admit that I do close up a bit when people insist that everyone experiences things the same exact same way that they do.  It leaves no room for people to be human.

Hundreds of thousands of people are involuntarily hospitalized each year.  While I won't be suggesting acknowledgment events in the book after the feedback I've gotten, I do wonder if just one of those hundreds of thousands of people might like someone to notice how painful their experience was and how hard they worked to get better, and perhaps be offered the chance to have their kids come have a piece of pizza with them when they were ready to go home. 

I am well aware that offering someone a "party" or a piece of cake doesn't make the bad of it go away and I never intended that.  There are some people who come in very sick and very psychotic, and who feel a lot better.  And by the 'exit interview' I was thinking some about the comparison to being raped -- -what could be worse than being raped and having someone tell you it didn't happen or wasn't that bad?  Might it help to be heard and have your violation acknowledged?  I hear that some people feel that wouldn't be safe and that if they were ever admitted again, they could be the subject of retribution.  I never meant for either an exit interview or a the offer of an acknowledgement meeting to be something that is forced, simply offered.  Sometimes it seems our commenters pit the patient as always the sane one -- as though people can never be sick or psychotic, or dangerous, or violent-- and the staff as purposely sadistic.  Patients can be sick, and there are bad people in all fields And believe me, I feel anyone who is intentionally cruel should be fired. 

Please feel free to post this in the comment for me on Mad In America.  Commenting here will be closed for a bit.