That’s all, folks

I’ve scoured the interwebs and continue to come up empty.  Suffice to say that the US is a predatory, brutal place with a societal culture that promotes predation.  As someone who was committed to patient advocacy, and yet failing miserably when I needed and sought help, I don’t want to lead others on a wild goose chase predicated on false hope and foolish optimism.  Those lead to betrayal, failure and more suffering.

That, in all of this medical mecca town, not a single psychiatrist, psychologist, psychiatric social worker or academic program offers any effective care and treatment to reduce unbearable psychological distress, nor is interested in doing so, speaks for itself.

That no one is interested on this blog or any other in discussing approaches or treatment alternatives sends a clear message.

Only I can find a place on the interwebs where no one else resides and Google turns up no results. WordPress putting all of my blog posts and comments on other WP blogs into spam was also a large factor in stopping.

In how many ways can one be ostracized?  I’ve lost count.  But I also just don’t give a damn anymore. They’ve got me where they want me – disappeared so as not to ugly up the place.

For the all one person (annalaw, that would be you) who read and commented, I am very grateful and appreciative.  I wish you the best in your quest for minimally acceptable care.

The reading list will remain in its messy, disorganized place.

And I will remain in this living hell until I can get myself euthanized and catch up to the social death.

Advertisements

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…)

Intentional Complications

Empty suit

Because THAT helps to explain this:  the fundamental devolution of the practice of medicine, psychiatry and nursing with the concomitant declining health and welfare of the citizenry in the US.

Truth?  Whose truth?

Branding?

Market share?

Global leadership?

Cui bono?

Harvard.

Substitutions

I follow food and nutrition science to some extent.  This caught my attention:

It’s been a profitable venture for the drug companies, as well as for the professors and their universities. Agriculture schools increasingly depend on the industry for research grants, a sizable portion of which cover overhead and administrative costs. And many professors now add to their personal bank accounts by working for the companies as consultants and speakers. More than two-thirds of animal scientists reported in a 2005 survey that they had received money from industry in the previous five years.

Yet unlike a growing number of medical schools around the country, where administrators have recently tightened rules to better police their faculty’s ties to pharmaceutical companies, the schools of agriculture have largely rejected critics’ concerns about industry cash. Administrators have set few limits on how much corporate money agricultural professors can accept. Faculty work with industry is governed by confidentiality rules that veil it from public view.

In certain ways, the close relationship between animal scientists and pharmaceutical companies has never served the public well. Few animal scientists have been interested in looking at what harm the livestock drugs may be causing to the cattle, the environment, or the people eating the meat. They’ve left most of that work to scientists outside of agriculture, consumer groups, and others who take interest.

But with the introduction of Zilmax, the situation may have reached a tipping point. Critics say some academic animal scientists have become so closely tied to the drug companies that they may be working more in the companies’ interests than in those of farmers and ranchers—the very groups that land-grant universities were created to serve.

Substitute patient for beef cattle and psychiatrist/primary care physician for animal scientist and voila! Patients growing enormous and iatrogenically ill and diseased on second generation antipsychotics, and their physicians so entangled with pharma and medical device industries that they fail to serve patients’ interests.

The Chronicle of Higher Education isn’t usually where I find in depth whistle-blower investigative reporting.  Read the entire article.  It will (or should) make your hair stand on end.

Ethics and malfeasance, anyone?

Social contract. In pieces.

Letters to Children and Other Juveniles

A little while ago, I dropped in at one of the many libraries in the area that sell books and ephemera.  A nondescript thin unmarked cover demanded closer inspection. In muted gold script, the title emerged, Letters to Children by Beatrix Potter, Harvard University Press.

Inside were several otherwise unpublished tales embedded in very kind and respectful letters to children that Potter had written.  Like another favorite author, Madeleine L’Engle, she was careful to get out of her own way and write of salience and thought-provoking ethics which all ages could enjoy and take away the gifts of essence.

It occurred to me that the ever louder and defensive whining tales of woe coming from self-proclaimed “good” psychiatrists might benefit from a session or two with Potter’s and L’Engle’s stories.

Here are some of the take aways for them:

1. Who is the subject of the tale?  Patients (others) or self (psychiatry and psychiatrists)

2. Who is the hero? See #1

3. Who and what constitutes the villain?  Patients, insurers, third party reimbursers, employers (hospitals, institutions, jails, prisons, lawyers, universities, patients), laws, regulations, society, colleagues, non-psychiatrists health professionals

4. What needs to happen for the hero to triumph? Patient compliance, better financial renumeration, more professional power, greater professional autonomy, more prestige (all this assumes psychiatry is the hero)?  Or in the case of patient as hero, recovery, respect, successful societal integration, independence, personal autonomy, belonging, self-efficacy, prestige, greater financial renumeration?

5. What are the dangers interfering with hero triumph? What are the resources the hero brings to bear on the dangers?

OK, so with that in mind, have fun re-reading your childhood favorites.  And take a gander at two recent posts penned by psychiatrists who define themselves as “good guys”, but do not specify exactly what that means for readers. The Steve twins – Drs. Moffic and Balt, have a go and try to engage with commenters who self identify primarily as people who had experiences as psychiatric patients and family of psychiatric patients. Refer to the list above and see if you can’t help them out in their obvious confusion and self-contradictions.

Hint: psychiatry’s subject is supposed to be patient well-being and health derived from a respectful and trust-based relationship with patients

 

Cui bono?

I haven’t blogged about meta psychiatry much.  If you are following the unfolding DSM debacle, you may well see the demise of extant US psychiatry (take it away, 1 boring old man). As I responded to Steve Balt’s weasel words excuse-filled post, I believe that psychiatry has broken the social contract. UPDATE: Steve deleted my response and apparently banned me from commenting. In a perverse way, I’m pleased because it validates what I am writing here.)  It deserves to have limits placed on it via licensure restrictions and practice proscriptions. It should be demoted to technician helper status, and it should no longer be viewed as having the right to call itself a medical specialty.  Indeed, psychiatrists should be mandated to practice as physician’s assistants – under the direct supervision and accountability by a physician.

US psychiatry is having a Flexner Report (pdf, but well worth the hassle) moment, and here’s hoping that a modern day Flexner – or committee – will appear, free of conflicts of interest (snort), and raring to delve into every psychiatry department of every medical school, academic medical center and private and public psychiatric facility.

The key question here is who benefits?  In the case of the licensed helping professions, the underlying ethic historically has been that the patient’s interests are first and foremost, and that the helping relationship is one of beneficence.

Well, let’s see:

Are there clear standards of practice and care in psychiatry?

Beyond that of assessment of “symptoms” and socially defined unacceptable and undesirable behaviors (dangerousness, aggression, agitation), and establishing a therapeutic alliance, no there are not.  You will not find any Cochrane meta analyses of psychiatric care demonstrating efficacy, patient cure or higher quality of life, effective palliation or patient satisfaction. There are no medical diagnoses which fall under psychiatry.  Bunches of symptoms labelled arbitrarily with “disorder”, but no biologically-based pathophysiology.  That falls under neurology, or as manifestations of symptoms of endocrine, cardiac and infectious diseases.

What are the drivers of psychiatry?

Sources of reimbursement demand patient diagnoses, even if there is no “disorder” present.  The absence of a pathologic diagnosis means that the psychiatrist will not be paid by a third party.  Ergo, the patient becomes the means to the psychiatrist’s ends. Stigma?  What the hell do they care? Well, actually, distress from stigma is a source of their business.

Practice and professional autonomy.  No one can tell the psychiatrist how to practice.  Indeed, the literature is filled with admonitions for psychiatrists to use their “informed intuition” and “professional judgment.”  There is no difference between this and the practice of quackery.  None.  It’s based on nothing scientific, reproducible and ethical.  Moreover, in using intentionally flowery and obscure terms such as psychoeducation and psychopharmacology, psychiatrists try to make patient education and medication prescription something mysterious, specialized and requiring advanced knowledge and practice. That is deceptive, inaccurate and serves only the psychiatrist’s interests in perpetuating a sham specialty.

How does extant US psychiatry practice benefit patients?

It doesn’t. Patients present seeking help for distressing symptoms – feelings, emotions, perceptions, thinking and behavior which interferes with their perceived quality of life. Alternatively, they present involuntarily when law enforcement becomes involved.

The therapeutic alliance is a dishonest relationship which is presented as one of equals, partnering to address distressing symptoms.  In reality, it is a sham cover for the psychiatrist to retain control and power and to coerce the patient into compliance with the psychiatrist’s ordered treatment.  Many, if not most, medications used by psychiatrists cause iatrogenic harm – up to and including death.  Patients are not routinely warned about these, and so cannot and do not make informed decisions about taking them.  The adverse effects of them are the most common reasons that patients stop taking them, which is entirely their right.

Psychiatric hospital facilities are prisons.  There is no therapeutic benefit to patients.  The routines used in them are designed to maintain power and control over patients by staff, to facilitate custodial functions (eating, hygiene, activity), and to intrusively observe patients/inmates.  Most deny inmates access to fresh air, direct sunlight and nature.  Diets are non-nutritive. Patients are denied visitors, their dignity, and their civil rights.

Most of all, the psychiatrist/patient relationship is judgmental, dehumanizing and designed to keep the patient under the psychiatrist’s “care” on a chronic basis.  The emphasis is on continuity, not cure.

Everything about this is unethical, unprofessional and wrong.

Why write about it here?

People who suffer with suicidality need a place of absolute safety to discuss their feelings of unbearable distress.  They need to be able to speak with someone who is knowledgeable about the distressors and their causes, tolerates having someone else share this distress, and has the capability and professional experience to support and coach them to lower their level of distress to the point that they can then address alleviating the underlying causes.

Patients need to be equal partners in the relationship, and their needs, wants, desires and functional goals should be paramount within the constraints of civil society. (Psychiatry is alone in hosting a forensic subspecialty and working for law enforcement agencies [prisons and jails] as well as serving as for-profit expert witnesses in court trials.)  There should never be a threat of law enforcement involvement as a condition of care.  There should be no threat of involuntary incarceration – forget about calling it hospitalization – it’s no such thing.

In the Reading List, I’ve included some programs and interventions which do this.  But to date, I’ve not found a single licensed provider of any sort who has the above skill set and practices by the stated objectives. And while support groups can be helpful in long term coping and adaptation, I think that acutely distressed people deserve to have competent, capable and non-coercive, humane care.

That care is decidedly not to be found within extant US psychiatry.

Treatment As Usual: Case Report

DSCN1759

Image by Michael 1203 via Flickr

 

Submitted without comment:

Outpatient psychiatrist: Patient came to her routine psychopharm visit expressing profound hopelessness and a desire for her life to end. She described recent incidents at the shelter where she is staying, including one where another guest took an overdose of medication and she (the patient) was distraught that she hadn’t recognized this (clinically) sooner.  She repeatedly said, “I can’t survive this…I want it to end.”  In addition to feeling overwhelmed and anxious about her state of homelessness, she expressed concern that she “would never feel safe anywhere.”  She denied suicidal intent but was unable to find any reason to continue her life and made numerous self-disparaging remarks.  She became increasingly distraught, crying and almost moaning in her chair.

Impression:

Since stopping her antipsychotic medication (intolerable EPS per patient) and decreasing her antidepressant medication on discharge from the hospital (to the street), the patient is faced with the reality of limited housing options and may likely face daily uncertainty about where she will sleep once she completes her time at current shelter – and is overwhelmed, panicked, despairing and hopeless about her life.  Her paranoid ideation has increased.  She sees no meaning in anything and wishes to die.  She denies immediate suicidal intent, but mostly due to lack of energy rather than lack of desire.

Plan:

With much persuasion, patient walked with me to the A(cute)P(sychiatry)S(ervice) where she will be evaluated for inpatient hospital admission.

APS psychology fellow note 4 hours after arrival:

Patient was tearful, depressed with poor eye contact.  Patient refused to talk to writer stating “I can’t talk, go away.” Writer was unable to complete full exam due to patient refusing to be evaluated at this time.  Patient is intermittently sobbing uncontrollably, saying nothing more than “I can’t” and “you have to let me go”, refusing medication and refusing to participate in interview. Perseverating on “you have to let me go” “nothing will help”  TP – perseverative -Insight poor Judgment poor Patient requires ILOC to establish safety, containment, and aftercare planning.

36 hrs later – Psychiatry fellow and attending consultation note:

Fellow: This patient was admitted for altered mental state with bradycardia and a serum diphenhydramine level of 489 mcg/l (toxic range).  Psychiatric consultation was requested for ? suicide attempt. The patient reports that she left the hospital yesterday, returned to the shelter at which she was staying to discover that her belongings (aside from medications) had been removed.  Pt reports having felt more hopeless and ingested unspecified number of her prescribed medications.  She reports that she did not want to hurt herself but hoped that this ingestion would kill her.  She denies having anything to live for at this point, denies intent to harm herself but feels “regret” for the outcome of this medication ingestion and reportedly “want(s) to die.”   Pt does report that much of her feeling hopeless is related to lack of shelter and job.  She attributes her “life situation” to being ostracized “for being a whistleblower” (related to prior living and job situation per medical record review).

Attending: I have reviewed the events/notes of earlier this week.  At present, she explains to me that yesterday, when she left here, she wanted to die and took pills in order to bring about her death and thought the pills she took would effect that outcome.  When she realized she did not die, she felt regret.  She still feels regret because she still wants to die and kill herself. Asked why she did not acknowledge this yesterday before she left here, she said that she knew she would be hospitalized psychiatrically if she had and she didn’t want to be.  I explained to her that caretakers are able to help her only to the extent that she is honest with them.  She is pessimistic that pharmacotherapy and psychotherapy can help her deal better with her problems even if they cannot take them away.  I explained further that both can help her to be more optimistic.  She denies any thought of wanting to hurt anyone else.  She denies that anyone here is trying to hurt her.  She feels her thinking is clear and in its usual state.

Impression: Delusional and depressive disorders.  She is pessimistic, despondent, and suicidal at present and meets criteria for involuntary psychiatric admission.  Continue suicide precautions.  Continue 1:1 observation.