Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen. All patient vignettes are confabulated; the psychiatrists, however, are mostly real. --Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)
As therapy continued with her, I heard how flat and tinny I sounded whenever I attempted to analyze what was going on between us. When I lapsed into too clinical a mode, our connection would wobble, and her alienation became palpable.
In contrast, as I began, in the face of her challenges, to let down my guard, our alliance grew stronger, and she became open to treatment. We would laugh together about her bringing me just the right greeting card or a flower from her garden — exhibiting her need to challenge “the rules” and exposing my need to interpret her actions. These interactions helped develop her capacity to observe herself in action, as she courted me in her Sherpa style.
I may have been a slow student, but eventually I understood: I was the one who had to change. From then on, when she saw that look in my eyes, I said yes, I did have a migraine. We followed episodes of the TV show “ER” together, and I told her where I was going when I left for vacation.
In all of his work, Swanson has found one recurring factor: past violence remains the single biggest predictor of future violence. “Any history of violent behavior is a much stronger predictor of future violence than mental-health diagnosis,” he told me. If Swanson had his way, gun prohibitions wouldn’t be based on mental health, but on records of violent behavior—not just felonies, but also including minor disputes. “There are lots of people out there carrying guns around who have high levels of trait anger—the type who smash and break things,” he said. “I believe they shouldn’t have guns. That’s what’s behind the idea of restricting firearms with people with misdemeanor violent-crime convictions or temporary domestic-violence restraining orders, or even multiple D.U.I.s.”
Over on Pete Earley's blog, he gives the text of a speech by DJ Jaffe, a mental illness advocate. Mr. Jaffe contends that those with serious mental illnesses constitute 4.2.% of the population and those people can be differentiated from the rest of the population, including the 20% of the population in any given year who have DSM diagnoses which are "mainly minor illnesses like anxiety." Jaffe would like to see those with real mental illnesses, who aren't the worried well, moved to the front of the line for services.
Sometimes, I like to bother pharmacists. They are the nicest people, and very patient about looking up medication costs for me. Once, I wrote a post called The Co$t of Being Depressed, where I compared the cost of anti-depressants. Today, I'm writing over on our Clinical Psychiatry News website about The Surprisingly High Cost of Abilify.
Here's the short form, but do surf over there for details:
I called three pharmacies and compared prices on Abilify.
Please remember, this data is for three pharmacies only
Over on Saving Normal, psychiatrist-blogger Dr. Allen Frances has put up a thought provoking article called We Should All Be Ashamed. Frances asserts that closing the state hospitals was the wrong thing to do : those patients now live on the streets and cycle through the jails. We haven't freed them, he says, we've abandoned them. Frances goes on to say that Dr. E. Fuller Torrey is right: our society needs laws that allow us to force those who need help into care and Representative Tim Murphy is right: we need to pass the Helping Families in Mental Health Crisis Act -- one that mandates states to have programs for involuntary outpatient commitment.
Is there any possible way to get this train back on track? First, implementing Tim Murphy’s Helping Families in Mental Health Crisis Act (H.R. 3717) would be a good start. Second, Congress should abolish the IMD (Institution for the Treatment of Mental Disease) exclusion. In fact, I personally believe that the federal government should get out of the mental illness treatment business altogether. They have been in this business since the passage of the CMHC legislation in 1963 and it has been all downhill. Let’s give the responsibility – and the federal money—back to the states and then hold the governors accountable for the results. They cannot do worse than we are doing now. Third, there needs to be further modification of state involuntary treatment laws and increased use of assisted outpatient treatment (AOT) and conditional release so that the small number of seriously mentally ill individuals who need these kind of services can be treated before they end up homeless or incarcerated. These three steps alone would go a long ways toward improving the treatment system."
Once they get to the ER, patients with mental health disorders are are often held without treatment for many hours, or even days, while they wait for a psych bed to open up – or for an assessment to determine they don’t need one. In an ideal world, those patients would be seen much more quickly, by qualified professionals, in a setting intended specifically for handling urgent psychiatric cases.
This is a short post to send you over to Clinical Psychiatry News where I wrote an article on an NFL.com television special "A Football Life" special about Brandon Marshall, the Chicago Bears wide receiver, who struggles with borderline personality disorder. It's not often that I get to write about football and psychiatry in the same post, and I always like it when successful people are public about their psychiatric disorders -- what better to help de-stigmatize conditions that are erroneously associated with people who have been marginalized?
Day Two of the American Academy of Psychiatry and the Law Conference
I picked up a number of tidbits from the poster sessions:
-250,000 juveniles a year are sent to the adult criminal just system
-3/4 of all juveniles serving life without parole were sentenced in five states
-Louisiana uses an assertive community treatment program to supervise and restore incompetent, nondangerous criminal defendants. This sounds like a good way to get people out of the hospital, or avoid having to send them there in the first place
-In Indiana, a survey was done of judges who have dealt with defendants claiming to be “sovereign citizens.” Most appeared in court for traffic violations or fraud rather than violent offenses. Tax evasion was least common charge.
-In a survey of PGY4 general psychiatry residents, most felt confident in their ability to perform sanity and competency assessments. Fewer felt confident in their ability to assess malingering or to participate in civil commitment hearings. This is concerning.
-Specialized processing centers (SPC) have been built for ICE detainees. They have 24/7 psychiatric coverage and freedom of movement, but no clinical review or medication over objection procedures.
The Bazelon Center has filed suit with the Department of Justice over the American Bar Association requirement to disclose disabling conditions like psychiatric disorders on the bar application, and over the requirement for some lawyers to work provisionally under supervision solely due to a history of psychiatric treatment. Proposed language to restrict questions about psychiatric issues is being considered.
The APA is updating its resource document on assisted outpatient treatment. The final document is not available at this time and the organization's position has also not be finalized.
There was an interesting talk by one of the people working on the development of the Stalking Risk Profile, a new instrument designed to predict the relative risk of continued stalking of one victim, the risk of stalking a new victim, and the risk of violence posed by a stalker. It has shown good interrater reliability based on the stalker typology, and good predictive validity between high and low risk offenders. (The overall recidivism rate was 15%, but almost all of that was due to stalking the same victim.)
The final session of the day was a panel presentation, with pro and con arguments, regarding whether involuntary non-emergency medication should be administered in a correctional rather than a hospital setting. The "pro" side noted that in some jurisdiction the waiting time to hospital transfer can be months long, and that appellate courts have upheld the use of these "Harper procedures" (after the SCOTUS case Washington v Harper) for pretrial detainees. The most creative argument on the "con" side was by Michael Perlin, who suggested that involuntary medication of prisoners was a violation of the Convention on the Rights of Persons with Disabilities (CRPD), an international human rights agreement which the United States has signed on to. He suggested that any kind of involuntary treatment or detention based solely on the presence of a mental disability was discriminatory and a violation of that document. A creative but not persuasive argument.
So that was Day Two.