Someone at another site noted that my recent posts had “venom”. Hmm, interpretation is always individual specific, and my run with the Bulworth ideology is not about being nice or respectful, because that was the point of the movie, the character was being honest and direct, as he felt his days were numbered anyway. As psychiatry continues to travel separate from the way I practice, the profession seemingly opposite from my philosophy about doing what is right and focused on patient needs first, well, where do you think Obamacare, managed care interventions, and the DSM 5 crap will take anyone like me?
Maybe there is an indirect assassination “plot” for the likes of doctors like me, just slow and insidious. So, these last 3 points for this final to the series can either reinforce I am spewing venom, or, being as brutally candid and direct you’ll ever read from a doctor.
1. You can’t the handle the truth. I think from listening in the office and reading at various mental health blog sites these past few years at least, there are plenty of people who have received mental health care that just ain’t ready to handle the truth to what are their needs. Frankly, I think Axis 2 pathology has increased dramatically in the last 10 or so years, perhaps comorbidly, but it is a primary player to what brings them into providers’ offices and surfing the net for clarity, but moreso endless bitching about failures in response to care interventions.
At another site that recently wrote a post about involuntary commitment issues, already the thread is taking off on how inappropriate and insensitive experiences have been for those who were forced into hospitalization. Well, yeah, people coming into care per this admission status are making the experience punitive (as #2 below will elaborate further), so, where is the motivation to be cooperative and invested in objective opinion? And, as I asked in that thread, where are all these explanations why involuntary committment had to be done in the first place? This false assumption that I INTERPRET from many of the comments is that doctors put people in the hospital at the drop of a hat is almost always that, false. I never have threatened to consider involuntary care at moment one when a person is verbalizing intent to harm oneself or others, or is flagrantly exhibiting poor judgment that can be seen as increasing risks to self or others in short time. I hesitate until no other choice is available simply because if the person has any ability to reason and problem solve, I want him/her to see the intervention is to HELP them, not HARM them.
But, and this will be noted moreso in #3, too many of my colleagues have and seem to still be too damn patriarchal and directive with patients, so, put an Axis 2 person in that situation, well, things don’t play out well, both in the community preceding the admission and well into the hospitalization. The way inpatient care has degraded into this “treat ’em and street ’em” mentality makes any involuntary situation all the more confrontational as the units want the patient stable enough to (and I know this will not be received well by colleagues, but it is what it is to me) basically dump him/her back to the community to deal with it. Sometimes that may actually be the best choice, it might encourage more investment to cooperate! But, what do characterological patients really learn from this experience? Just validate that treatment is an enemy, until proven otherwise.
Why so many people here on the net are tentative or hesitant to raise the question what to do with Axis 2 issues, both in the office and on the net, well, you all just play into the hands of characterological disordered individuals who will prey on such diplomacy and caution. Alliances are crafted and continuously molded, so what happened to all that countertransference we learned about in residency? I haven’t forgotten it. And, having both the blessing and curse of growing up with Axis 2 people, I know what the issues are.
Oh yeah, I think I know why personality issues are avoided, Axis 2 was not a reimburse-able diagnosis by the end of the 90s, so, why waste time formulating that in the diagnostic impression. It was and still is easier to just diagnose Mood Disorders and get paid for it. Whatta sell out! But, to not address it at least covertly here on the net, a failure!
Sorry to piss off some of you reading here, but, that is my interpretation. Disagree and dissent away as interested.
2. Court referrals. The above picture for me is priceless for what sums up the process in courtrooms these days. Judges have the mental health expertise that I have for fixing a car. But, funny how I have been practicing for 20 years now, and have yet to get that call or other preemptive contact from a judge asking me how I would handle a referral from court to get a patient into mental health care.
As I noted above about the consequences in presenting treatment in a punitive light, ahh, do you really think a patient who is told “go see a psychiatrist or go to jail” is going to come to me invested and interested in psychiatric opinion?? I have met a couple, because I was fortunate to meet these few people who had some insight and judgment to realize the status quo was getting more convoluted and fraught with consequence, so exploring they might have a psychiatric problem that got them arrested or confronted with major civil matters and in front of a judge saved them wasted time behind bars.
Oh, and this Drug Court stuff, again, for every person it might help, count the next 5-7 people just watching the clock tick until their probation time is up. All they do in my office is minimize, rationalize, deflect, deny, and drug seek with prescription meds. Gee, sounds like they are still entrenched in addiction mentality. Thank you, your honor, while perhaps a sizeable percentage might actually benefit from being in mental health care, at least therapy, the other half are just trying to drag me into their ongoing bullshit.
As per #1, addicts don’t want to hear the truth. Ironic that reference is from a court scene, eh? But, I won’t just bitch in this section, I have a solution to offer, assuming this is a possible conversation with that first call from a judge:
Judge: Dr Hassman, I have a young man/woman coming into my court this morning who I sense might be Bipolar, from what I have read in the discovery documents to now. What can I do to end this disruptive, destructive cycle that is fraying the relationship between this person and family that appears exhausted?
Dr H: First of all, thank you for calling to ask me my perspective. I don’t have an easy answer, your honor, because right now, all that person is seeing and understanding is that their freedom is being denied. Has the person voiced any sense of accepting responsibility for the problems bringing them into a courtroom?
J: From what I have read, not really. The person has been obstinate, rude, dismissive, and claiming he/she has nothing to do with the problem that has legal consequences. Documents show this is not the first time such events/incidents have happened, and the patient has been minimally, if at all, involved in past mental health care. Oh, and I think there might be ongoing drug use in place as well.
Dr H: Hmm, the drug use will be a major stumbling block to any chance at effective mental health care as my abilities and adjunctive services I utilize at the mental health program do not have structured substance abuse services. Do you have access to a Sub Abuse Pgm that can provide care while minimize the services appear punitive?
J: This issue is beyond the simple scope of a Drug Court assessment, but, I might be able to tie it in with services that make treatment remain voluntary, so the patient will not feel coerced or subjected to harsh scrutiny, if he/she is invested to avoid serious incarceration.
Dr H: well, if the person can accept the need for abstinence and continual recovery for now, and can voice in a spontaneous manner that he/she may in fact have mental health problems that at least may contribute to substance abuse possibly self medicating in intent, AND, the person is willing to be interviewed with collateral contacts who are reliable, sympathetic, and supportive to this person’s needs and goals that are intended to be healthy and responsible hereon, I think I could be a resource.
But, please note this, I am only able to see them for voluntary help, and if the person chooses to not want to continue care, all I will provide to the court in the future is documentation of what I sense is the provisional problem(s), what is the treatment plan that has the best impact for stabilization and resumption of healthy function, and when this person attended visits and when they did not as asked to commit in follow up. I am not going to refer to what the court advised, I will not give any sense I work for the court, and I will not EVER raise the consideration that should this person not continue care then he/she might go to jail. I know that is a sizeable risk, but I will not present treatment in any punitive light.
J: I agree, and when I hear the remainder of the case, I will ask the patient to try to see that there is a choice, that being in care is to help, not to deflect or absolve responsibility, and that they have the right to refuse. I have the right and the responsibility to the community to do what is in the best interests of all, and if there is no interest in change, then that is why I will have to consider incarceration or other punitive actions. I hope the person has some insight and judgment to see the best choice.
Dr H: So do I, I hope the person will come in with an interest to change and be healthy again.
I know, writing such a theoretical dialogue is a bit lame, but, it’s a start. One I have yet to ever have. Where are all these Forensic Psychiatrists who might at least somewhat overlap in what I offer above and advise the Judiciary System such ideas, so people are a bit invested to pursue care? Yeah, I am not holding my breath that many in this subspecialty would go those 9 yards to help non-forensic colleagues. Not enough money to make that effort, eh?!
3. Starry Night, what about tomorrow? Some of you who have been around the net and mental health blogs for several years might recognize this above picture, as it was from one of the first blogs I was a regular reader, Furious Seasons. The author, Philip Dawdy, actually had one of the better perspectives regarding mental health care issues from the perspective as a non clinician. It is a shame he let it lapse and then disappear, but, I guess from what very little I know about his situation, he must be high on life now, what with Washington State legalizing marijuana use. Just an opinion on this, I have no idea what he is doing.
But, the transition here is simply his ongoing criticism of psychiatry with medication primarily was inspiring to me, as there were some other clinicians who would comment and echo at times my perspectives about the direction of psychiatry. Unfortunately, it was then I first encountered the frank ugliness of antipsychiatry, some of it so unfiltered and brutal, I finally gave up trying to encourage as I could to have Mr Dawdy do a little censoring. Ironic I finally decided to be so rude to force him to censor me that he did so, yet, some of the most abusive shit I ever read continued on.
Makes me wonder how many readers in that lobby do come here and read what I write, but at the very least are frustrated with my moderation boundary. I have said it before and will do so now, and again later where it applies, you want to write to me and keep it respectful but dissenting and passionate about perspective, I will post any and all comments. I am not sure what happens if someone uses an “Anonymous” alias, so I will explore that if the system boots it, I will have my tech guy see if it can be altered to allow anonymous commenting. But, KNOW THIS, I respect anonymity, but, I do not respect nefarious agendas without some level of accountability. This site will never mirror Furious Seasons in any way. I write to inform, educate, and enlighten, as well as vent. I do not tolerate zealotry! Project away you feel I am a zealot, but, it won’t stick.
This site seems to work for me. Isn’t it a shame that honesty, candor, and directness is often driven when there is no other choice at that point? And in my profession, where are all the advocates, the true impassioned believers of the Hippocratic Oath, people who embraced the committment to become a physician and then psychiatrist to truly help people? Have so many of you sold out that you actually give a little validation to the endless onslaught of the mantra to the antipsychiatry lobby that the profession should be eliminated from our society? Is the silence and lack of passion for true caring really acceptable to those who practice psychiatry today?
I leave you with this picture that says it all, especially from my C & A colleagues:
You can’t medicate life. It is a multifactorial process, both in causing illness and treating it. Frankly, there should be global outrage the DSM 5 removed the Multiaxial format to assessment. What a freakin’ sell out that says alone!
Thanks for reading this post, long, but, well intended.