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…)

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Poor Put Upon Psychiatrists

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MovieDoc is perturbed that patients who are contemplating suicide telephone.  Instead, he avers that they should be telephonally instructed to hang up and call another number.

Despite the ubiquitous “If this is an emergency, hang up and dial 911” message I wonder how many patients who are sufficiently ambivalent about ending their lives to call their psychiatrist would call 911 instead. There seems to be an expectation (standard of care?) that psychiatrists can somehow talk them out of it over the phone, or attempt to stop the patient by involving 911 or other resources. I find it ironic that many argue that video conference (eg, Skype) is inadequate for even routine psychiatric encounters and yet expect psychiatrists to, on the spur of the moment, handle a life or death situation over the phone. Why not send these calls to the people who handle them all the time, crisis lines, and stop trying to be the hero like one of those movie psychiatrists?

In Sybil Dr. Wilbur goes to her patient’s apartment to rescue her. How far should one go to stop the patient from killing herself? Why stop with a telephone call?

Should we pretend to do something we cannot do? Does providing access outside of an appointment encourage or reward dysfunctional and potentially dangerous behavior?

“If you’re suicidal, leave a message and you’ll get a free telephone session with your physician who wants to be your hero and rescue you and provide you with attention and make you cared for, warm and fuzzy.”

I don’t disagree that patients shouldn’t try to contact their psychiatrist, when they have one, but my disagreement is for different reasons. MovieDoc buys into many myths which have been exposed as such by Thomas Joiner. For example, the myth of impulsivity, selfishness and suicide notes are addressed:

To my knowledge, no study has reported a rate of note leaving among suicide decedents to exceed 50%. Moreover, most studies find rates between 0% and 40%4; a reasonable average rate would be approximately 25%.

 

Why are suicide notes so rare? Some have reasoned that because impulsivity is involved in suicidal behavior, suicidal persons often kill themselves before they have a chance to write a note. There are problems with this viewpoint, however. A major problem is that it draws on the distinct myth that dying on a whim is common. Another problem is the lack of empirical support that compares those who leave notes with those who do not. If it were true that note leavers are much less impulsive than those who do not leave notes, then this distinction should be easy to demonstrate in forensic studies that examine the lives, characteristics, and personalities of decedents. This difference has not been clearly demonstrated.

 

The relative rarity of suicide notes reveals the state of mind of those about to die by suicide. To say that persons who die by suicide are lonely at the time of their deaths is a massive understatement. Loneliness, combined with alienation, isolation, rejection, and ostracism, is a better approximation. Still, it does not fully capture the suicidal person’s state of mind. In fact, I believe it is impossible to articulate the phenomenon, because it is so beyond ordinary experience. Notes are rare because most decedents feel alienated to the point that communication through a note seems pointless or does not occur to them at all.

Suicide hotlines are staffed by people with all sorts of education, backgrounds and skill sets. There are no therapeutic standards of practice.  There is no accreditation, licensure or certification requirement for crisis hotlines or the people who staff them.  Caller beware.

As a caller, I’ve been treated to someone chewing his food and multiple hang ups (“I’m sorry I can’t help you. I have to go now.” Click. That was verbatim, and so must be in the script for getting rid of undesirable calls)

I refuse to ever have contact with any aspect of hospital based psychiatric services, as do I suspect a majority of people with past suicide attempts. The trauma and harm that caused is something I won’t expose myself to again.

But I would not contact a psychiatrist either since the power to force treatment is an ongoing threat. Suicidality is obviously not safe for me to discuss with anyone, and until euthanasia is “on the table” I can’t foresee trusting any provider enough to discuss core concerns. Moreover, I have no desire to distress someone else, provider or otherwise, with my concerns.

All this to get to the point that I hypothesize that there really isn’t a big patient population that would be likely to call their psychiatrist with lethal suicide intent.

Just as most people who commit suicide don’t leave notes, I doubt that they make impulsive “save me and be all warm and fuzzy about it” phone calls, either. I certainly learned that no one is interested, nor can help, via that route.

Indeed, I learned that there is no useful therapeutic treatment for suicidality. The current standard of incarceration (they call it containment), assaults and batteries (forced medication, restraints, isolation, refusal to allow patient chosen visitors to be present) and intrusive observation sans human interaction (unskilled people who do not speak to, touch or care for patients, but who literally remain in views at all times) is dehumanizing, demoralizing and confirms the extant hopelessness. It doesn’t ever address suicidality and its attendant concerns of thwarted belongingness and perceived burdensomeness.  It does nothing whatsoever to relieve the unbearable distress that predicates suicidality. It’s all about restraints, control and power.

Discontinuing mental health services and contacts was necessary to halt distressing assessments that were conflated with care and continuing trauma from a lack of effective care.  At least the iatrogenic harm stopped.

Like many others, I came out worse than before I received “treatment”.

So I find it ironic that the psychiatrist feels undue burdens in the theoretical situation of a patient contacting him or her with a perceived degree of unbearable distress.  Is it any wonder that the suicide rate is highest for psychiatrists?

When they remove the double speak and have that oh-so-critical insight into what will be done to them if they seek treatment for suicidality, psychiatrists, like most physicians, do not seek treatment and avoid seeking peer support or disclosing their “illness”.

The biggest walking, talking, suiciding ads for anti-psychiatry are distressed psychiatrists.