Degree of Writhing

She was impaled by a person. Along with the act, she was informed that she would remain there and that the means to remove her would be withheld. She was informed that should she appeal to others who would contact the impaler for collateral information, that she would be described as malign, foul and unwanted. A few others who knew what was in store for her promised their support and help.

She was impaled for all to see.

She writhed and contorted and struggled to reach something that could be used to wrench herself loose. Those who promised help disappeared and did not answer her calls for support. They did not help, and they did not call on others to help.

She found herself alone.

The pain, the agony and suffering were unbearable, just as the impaler intended.

But the place of impalement was strategically designed to cause the slowest dying possible, and was designed not to make death come earlier. It was executed to cause the maximum degree of suffering with full realization of the fate and future of the impaled writher.

One by one, and sometimes concurrently, the impaled person used up her means of escape. She learned that to struggle was futile. To writhe more actively only increased pain and fatigue. She couldn’t get to sleep, couldn’t stay asleep, and she awoke very early. Sleep soon became no escape and provided no rest.

Years passed, and on she writhed and agonized.

At this point, she realized that she was out of all resources, and she called out for help from learned helpers.

The highly credentialed, learned helpers poked and prodded and caused even more agonizing pain as they slowly and methodically assessed her symptoms. Although she repeatedly told them that she was impaled – Look! I need people who are qualified to remove what’s holding me fast to free me – they ignored her begging and pleas.

The learned helpers decided that her writhing and grimaces and pleas for help could all be treated as symptoms of depression. She was told that she was going to be treated for her pessimism and refusal to believe in hope. She was forcibly medicated and restrained so that the writhing was contained. She was told that treatment was to keep her safe.

As she adjusted to the medication, she saw her body react to the derangements done it by the sedating, restraining chemicals. She struggled to writhe and react to the agony of the raw and festering wound. But she learned to be silent and to deny that suffering to the learned helpers lest they inflict more restraint, punishment, containment and contribute to her agony.

Some helpers came only to stare. Some to ridicule. Others to condemn. A few saw opportunities for sadism, and they kicked her, made open fun of her and reported to the treating learned helpers falsities designed to induce the learned helpers to inflict more treatment and up the induced agony.

Some of her treatment involved being instructed on how her thoughts were negative and to employ strategies to replace negative thoughts with hopeful ones. Another treatment involved instruction on maintaining distress tolerance. Both of these considered writhing as something to be abolished. Neither strategy dealt with removing the wounding weapon and treating the gaping, festering, infected wound.

It was apparent that this situation was permanently incompatible with life. She decided that instead of struggling any longer to free herself, that she would instead, simply try to find a means to achieve a painless and peaceful death.

But the learned helpers decreed that this was evidence that she was psychotic. Therefore, she would be contained until she was deemed “safe”. But the definition of safe was solely that she would not try to end her life.

Safe did not apply to all of the others who were content to have her suffer or to contribute to her agony and suffering. Safe did not mean a secure home, safe did not equate with a means by which to support herself, safe did not mean acceptance and welcome by others she deemed potential neighbors, coworkers, friends, physicians.

She was told that there are many treatments for her symptoms. She learned that they conflated treatment with efficacious, benign, therapeutic and beneficial. She learned that treatments were risky, dangerous, caused temporary and permanent harm, and did not address the causes of the symptoms.

She was told that the learned helpers decided on treatments based on their professional judgment. She learned that treatments are determined largely on the whims and beliefs of the learned helpers, and often they are chosen to punish the person for their audacity to exhibit distress and to admit that their underlying problems are not being helped.

And so she remains impaled, actively looking for the means by which to give herself a painless and peaceful death while all around her, the means to remove her from being impaled are withheld.

She remains a freak, a pariah, and an untouchable. Indeed, when she was contained and forcibly medicated, no one touched her except to wield a needle and crowd her into a locked cell sans furniture – no window, a security camera, a cage. Just herself impaled.

No one spoke to her except to poke, prod and exacerbate her awareness of her suffering by ongoing clinical assessments, each designed only to elicit symptoms and to ignore root causes.

So as the means to achieve a quick and painless death are not within reach, she has decided to passively bring about her death by no longer eating.

She remains out of sight knowing that no one will look for her. No one wants to see because when they do catch a glimpse, it angers and disgusts them to see her writhing in their midst. It is not pretty, being associated with her could cause a risk of social or work harm (guilt by association), and she has been deemed worthless.

She can’t wait until it’s over, and she looks forward to being too weak to writhe, too weak to comprehend the agony and too weak to care. Those signposts mean that the total and permanent end of her hell at the end of the learned helpers’ road of good intentions is finally within reach.

Advertisements

Riffing off A Powerful Message

A week’s worth of (medicated) sleep, and my noggin can at least process a few thoughts, here and there. 1 boring old man published an important post titled, A Powerful Message.  He chronicled the increasing clamor of psychiatry to use a neural circuitry model as evidence of psychopathologic causality and therefore an avenue for research and treatment.  I had noticed this, too, with increasing alarm and a sense of deja vu. I yammered a bit in a comment:

As a long time critical care nurse and educator, I witnessed an enormous transition in thinking about the care and treatment of myocardial infarctions (heart attacks). Care and treatment initially and historically was focused on complete bed rest and inactivity – up to and including only allowing room temperature food and drink lest cold irritate the vagus nerve. As the plumbing and electrical circuitry interface with the muscle stimulation and perfusion became more well known, treatments became more aggressive – getting patients up and moving right away, reperfusing coronary arteries and stenting them, ablating lesions, etc. Then the focus spotlighted statin use for prevention, concomitant with pharma DTC advertising and KOLs. Only recently has any of this been questioned, and lo and behold, stenting and preventive statin use may not do anything at all in terms of disease prevention.

Not for nuthin’ has clinical depression been found to coexist and correlate with heightened morbidity and mortality with of heart disease.

Patient stays in critical care units for heart attacks (MIs) went from 7-10 days to 1-2. Of course, patient education, diet teaching, stress management, socioeconomic assessment went out the window. In other words, self management and quality of life factors were ignored and abandoned. Patients are sent home with prescriptions, stents, pacemakers, automatic internal defibrillators and all manner of coronary hardware, and sometimes followup appointments. They are not linked to case managers, community resources and psychosocial supports.

The forces of capitalism, free markets and decreasing corporate regulation have converged to erode worker protections, environmental protections, food safety, community development (corporations receiving tax breaks, outsourcing jobs to other countries and pulling up stakes, leaving communities dying on the vine), and overall, contributing to the deterioration of social life and community throughout the US.  Vicious and poisonous politics have contaminated the well of civil discourse.

Whither health and well-being?

Here, my collegiate roots show.  Case Western Reserve University’s Frances Payne Bolton School of Nursing and the Department of Nursing Education, Teachers College, Columbia University, both were founded on the critically important work of nurses who established, grew, and nurtured public health and psychiatric nursing theory and practice.  My education was based on the principles and practices of Lillian Wald, Hildegard Peplau, Virginia Henderson, Isabel Hampton Robb (yes, the Robbs of Johns Hopkins and later, Lakeside Hospital of Case Western Reserve – this hospital was noted by Flexner in his famous Report on Medical Education, for serving as an exemplar), and Mary Adams, pioneer in gerontologic nursing and later a Dean at her home state, South Dakota’s State University School of Nursing.  These names will mean nothing to almost all members of the public, physicians, and sorry to say, nurses.

But I hope you’ll click on the links because their work has critical importance and influence on the individual, family and community health and well-being of Americans today. What you will see is their universal concern with the immediate and larger social and community environments which affect health and well-being of the targeted patient populations.

Physicians, nurses and indeed, all members of the (licensed, ergo, regulated) helping professions have an obligation to address, influence and lead policy and programming which are congruent with and supportive of a healthy environment and social life.  Those include wages which allow adults to work a single job and provide for safe shelter, clean water and air, nutritious fresh whole foods, reliable transportation, access to education and natural recreational facilities and adequate protective clothing for themselves and dependents.  It means assuring clean air and potable water.  It means assuring access for all to basic communicable disease prevention: vaccines, safe food, zoonoses prevention.  It means worker protections which promote tolerable physical and psychological stress levels.  It means protections for whistleblowers – rewarding workers for upholding ethical business, research and professional ethics.  It means promoting civil discourse and discouraging ostracism – whether that be racism, bullying, intimidation or any other type of behavior which is exclusionary.

Embracing the classical virtues and publicly upholding the inherent worth of every person will lead more to health and well-being than any pill, potion, invasive treatment or state of the art assessment tool.

The bottom line:  Each and every member of a helping profession by the social contract is an agent for social change.  Without that, patient treatment is devoid of care. And treatment will only palliate and blunt symptoms, rather than address disease and distress causality. Futile, impotent and, ultimately, destructive. Like this, perhaps:

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.

Does Repeated Suicide Assessment Give Salience to Suicidal Behavior?

Insulin shock therapy is given in Lapinlahti H...

Image via Wikipedia

Anecdotally, I avoid situations in which I am assessed for suicidality.  It’s intrusive, distressing, and the assessment isn’t used to provide relief from the distress.  For me, it’s a well known risk:harm without any benefit.

“Generally speaking, there is no history of providing psychiatric treatment in the emergency room setting,” says Elizabeth Wharff, director of the Emergency Psychiatry Service at Children’s Hospital Boston. “Since the late 1990s, we have seen a significant increase in the number of cases where an adolescent comes to our emergency room with suicidality and needs inpatient care, but there are no available psychiatric beds anywhere in the area.”

Given that the highest known demographic risk for suicide is that of previous suicide attempt, a couple of studies seem to lead to the notion that the current standard of practice of repeated and frequent assessment of suicidality without treatment to reduce the underlying distressors may actually be contributing to the development of suicidal behavior.

In the first study, demographics of suicide risk after the first hospitalization for a mental illness was explored.

Patients with any major psychiatric disorder are at significant risk for suicide after their first hospital visit, according to new research.
~snip~
Dr. Caine noted that although rates of suicide were less than what other researchers have estimated in the past, they were still quite substantial.

“I think this study really teaches us that all those prior results were in the right direction, but we’re now seeing much more clearly what the proper magnitude is, and what the burden of suicide is.”

“You can also clearly see that the suicide risk continues to climb over years. Certainly there’s a steep climb in the first year after hospitalization, but it continues to climb. So, this isn’t something you think about just the first day or week or month. This is something you think about for years,” he concluded.

It would be reasonable to think that hospitalized patients would have been frequently assessed for suicidality and behavior without receiving any treatment to reduce distressors other than masking symptoms with psychotropic medications.  The overall hospital experience is so antitherapeutic and noxious that overwhelmingly, patients avoid rehospitalizations. But they may leave with heightened acclimation to suicidality by way of the concept discussed in the following study.

The second study deals with understanding mortality salience:

Why did the approval ratings of President George W. Bush— who was perceived as indecisive before September 11, 2001—soar over 90 percent after the terrorist attacks? Because Americans were acutely aware of their own deaths. That is one lesson from the psychological literature on “mortality salience” reviewed in a new article called “The Politics of Mortal Terror.”
~snip~
The fear people felt after 9/11 was real, but it also made them ripe for psychological manipulation, experts say. “We all know that fear tactics have been used by politicians for years to sway votes,” says Cohen. Now psychological research offers insight into the chillingly named “terror management.”

The authors cite studies showing that awareness of mortality tends to make people feel more positive toward heroic, charismatic figures and more punitive toward wrongdoers.
~snip~
Awareness of danger and death can bias even peaceful people toward war or aggression. Iranian students in a control condition preferred the statement of a person preaching understanding and the value of human life over a jihadist call to suicide bombing. But primed to think about death, they grew more positive toward the bomber. Some even said that they might consider becoming a martyr.

As time goes by and the memory of danger and death grows fainter, however, “morality salience” tends to polarize people politically, leading them to cling to their own beliefs and demonize others who hold opposing beliefs—seeing in them the cause of their own endangerment.

Isn’t that interesting! If thinking about mortality and death can induce salience, that would seem to be generalizable to suicidality outside of martyrdom.

In Joiner’s Interpersonal Theory of Suicide, he speaks to the idea that people get acclimated to the idea of suicide.  Frequent assessments of suicidality delve into all of the mechanics of committing suicide:  does the person have a plan, if so, describe it in detail, how will they access the supplies and resources necessary to carry out the plan, where will they do it, will they leave a note, do they have reasons for not doing it, etc.  Even when people deny any and all of these aspects, bringing them up over and over again (let’s call it externally applied rumination) promotes acclimation to the idea of suicide behavior, if not also reinforcing the suicidality (perceived burdensomness and thwarted belongingness). In other words, the assessments serve as mental rehearsing or practice without any treatment whatsoever outside of direct observation (not a treatment), incarceration/involuntary hospitalization (doesn’t treat anything, and increases distress), and removal of the stated intended means (TSA and box cutters, leading to shoe bombers, then underwear, then turban bombs – a moving target, NOT a treatment for suicidality).

Won’t You Come In and Set A Spell?

I’d like to invite one and all who think about dying, wanting to die, plan your own death, attempt(ed) to die, study these thoughts, beliefs and behaviors or care for or about those who do, to help me in my exploration of alleviating distressors “upstream” from suicidality.

It occurred to me that survivors of suicide are usually described as family and friends of those who died by self inflicted death.  But what about those of us who remained alive after our attempts?  I haven’t found a term for that. Isn’t that interesting?

And what about those of us who find no relief in having remained alive after suicidality?  Or who don’t find relief from suicidality?

Perhaps there is belongingness and worthiness to be found in helping those who are navigating – mostly alone – these very rocky shoals.  Maybe bringing your wisdom, experience and perceptions in how to regain thwarted belongingness and regaining a real and abiding sense of purpose and meaning to someone who is suffering will help you to acquire the same attributes.

I was thinking about the study out today that demonstrates a deep and broad lack of trust by people with depression of their physicians. Then I thought about the known problem of medical students’ reluctance to seek help for mental illness.  I think there may be a lot of overlap in these two studies in the following areas:

There is fear of the negative consequences of reporting symptoms of mental illness – stigma, loss of career, loss of income, loss of health insurance, loss of healthcare (after a psych diagnosis, the quality of healthcare goes down significantly and dramatically as symptoms are chalked up to psychosomaticism and preventive healthcare doesn’t include aggressive care for psychotropic medication adverse effects),loss of personal relationships, loss of home, loss of social standing, loss of social roles, loss of self worth.  There is also the fear of coercion in accepting treatment.  And there is fear of undesirable effects of treatment.

But in admitting suicidality, there is a real danger of losing one’s civil rights, of being detained, incarcerated and treated against one’s will, of being publicly humiliated and shamed, and worst, of being intrusively assessed and evaluated with no care which alleviates intolerable distress.  Every single time I tried to bring up suicidality and how to deal with it, the treater instantly launched into the “dangerousness” assessment.  I eventually learned to clam up immediately and not to bring up suicidality again.

Is it any wonder that we scratch our heads and can’t figure out why people attempt suicide then?  It’s really because no one wants to know the lived experience – the phenomena – of suicidality.

The psychological autopsies are largely stupid, in my view.  There are living, breathing, distressed people who are more than willing to explain if only someone was there to be open enough (and not terrified) to listen and to help work through the distress.

I think that “someone” is those of us who experience suicidality. We may be our own best resource.

So if this speaks to you, consider yourself welcome.  Bring your best – critical thought, analysis, resources, references, support – and help to build ways to lower distress, prevent it in the first place, and find some relief for yourself.

 

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.