Poverty of Thought

Steve Balt wrote a post about some of his take-away thoughts from the American Psychiatric Association conference.

Commenters responded with thoughtful, illuminating insights about the gestalt of extant American psychiatry.  I was gratified to read that David Healy‘s Pharmageddon book is being cited as important.  He emphasized understanding the history of how capitalistic forces have emerged as the predominant force in shaping psychiatry and in shaping policies and practices which directly affect patient treatment (I refuse to use the word, care, relative to psychiatry and mental illness treatment, because it has specific meaning in the helping professions, and it is absent here.) and patient outcomes.

Steve’s post and your response, along with Emily Deans’ highlights a type of “poverty of thought” rampant in organized psychiatry. One cannot successfully treat people without the people. The old adage, “the surgery was successful but the patient died,” is apt for this field, too.

From assessment – how do you know you’re asking the right, germane, and appropriate questions? (glaring example: asking patients about suicide plans instead of about intolerable psychache and unbearable distressors. The first results in patients’ loss of civil rights and incarceration/observation, etc., the second SHOULD result in an urgent/emergent treatment intervention to lower the levels of immediate distress and to devise a treatment plan to reduce/eliminate the causative distressors. But that would mean knowing the patient, his living conditions and intervening where social justice is required. Ew. Messy. Takes longer than writing a prescription.)

To patient relationships – currently based on legal coercion, deception, and adverserial threat

To treatment – psychotropic medication, invasive surgery, inducing seizures and electrical stimulation, plus a dollop of who-knows-what talk therapy

To outcome goals – treatment adherence (do patients name their goals of being that of treatment adherence? /derisive snorting) which are unrelated to patients’ perceptions and functions in quality of life

Everything. Everything is oriented toward the psychiatrist. These are psychiatrists‘ interests at work. Patients are simply objects upon which to act, and are the means toward psychiatrists’ rewards: professional reimbursement, the source of research funds, the means to publication, and fodder for career recognition and success.

It’s Alice down the rabbit hole or through the looking glass.

It’s wrong.

But that it’s making more psychiatrists increasingly uneasy and uncomfortable is a good thing.  Eventually, that uneasiness will increase until it becomes an unbearable, distressing force, and action will become inevitable, if not impulsive. (Yes, I’m making a sarcastic swipe at extant suicide risk assessment, but I’m not going to advocate for incarcerating the poor psychiatric victims – in this case, the psychiatrists.  Maybe a little cognitive behavioral therapy so that they can recognize their distorted thoughts, and a round of ECT to jolt them out of their depression about their situation…)

What’s therapeutic about that?

The environment about where people are assessed and treated when experiencing a crisis of distress is critical.  Two bloggers recently addressed how much of a difference in help and harm leading to very different outcomes the physical treatment environment made here and here.

A recent post on the Bipolar Advantage blog discusses how to better help people during mental health crises, and proposes that “much of the hostility that [people who are part of the anti-psychiatry movement] have comes from bad experiences when in crisis.” I would absolutely agree.

When John had to enter the hospital a second time two weeks after his first, week-long stay, it was a real struggle to convince him to go because his first experience in the hospital had been such a negative one. I, on the other hand, have only gratitude for the people who helped me during my hospital stay.

It seems to me that mental hospitals could learn a lot about how to handle mental crises from the way general hospitals handle physical emergencies.

Many of the examples included actions by physicians and nurses that escalated and increasingly distressed patients already critically distressed.  In a comment on the Bipolar Advantage post, I summarized the desires of commenters in designing a helpful environment:

  Essential needs:

Dignity protected
Respectful
Family/significant supporters’ unrestricted presence
Advocate present
Comforting
Reassuring
Coaching
Partnering
Truthful and transparent information
Autonomy preserved
Planning for post-crisis self-management
Safe medication administration (right drug, right dose, right route,  right time, affordable, accessible, acceptable)
Tools for successful disease management and healthy living provided

Environment:

Medically therapeutic
Eliminate law enforcement/incarceration/containment aspects
Clear written rules – same as hotel room/gym/spa rules of conduct –         NOT  punitive/control/power-based

Health:

Healthful foods served appealingly: open kitchen
Privacy for rest and sleep
Ability to get sun, green space/nature and fresh air as desired
Meeting rooms and lounges for care, socialization, quiet activities (meditation/exercise/reading/contemplation) and care planning
Clean, attractive and non-odiferous patient care areas

That doesn’t look like to much to ask. In fact, it looks like the run of the mill hospital quality standards for every other service except psychiatry.