Come Meet The Shrink Rappers in Philadelphia

We will all be at APA in Philadelphia next weekend and we'd love to meet you.  Click HERE for a complete list of our presentations.


First, the age-old Philadelphia question: Jim's or Pat's for the best cheesesteak?


Where we will be:


Sunday, 8 AM- 12 Noon (no, we didn't choose this time), we are giving a seminar on Blogging, Podcasting, and Writing Books for the Public.  We actually know something about these topics.  I believe the seminars are listed with the courses on the main schedule, and ours will be held at the Marriott.


Sunday, 12:15-1 Find us in the Exhibition Hall at the Johns Hopkins University Press booth, we'll be signing copies of Shrink Rap.

Tuesday,  1:30-3 We will be doing a workshop on healthys and New Media: Gaining Control of our Specialty's Image.  Steve from the Thought Broadcast blog and Dr. Bob Hsuing ("Dr. Bob") will be with us for a panel discussion.


I will be putting up a spot on the blog for participants to give us some feedback on the sessions. 

19 days left...

CLICK to go to Tribute page thanking donors... and Roy is winning... you know you want to give in Dinah's name.

Psychotherapy as a Model for Positive Relationships

One of our regular readers wrote in a comment that she's read how the psychotherapeutic relationship is supposed to  model a healthy relationship for the patient.  I hope I got this right, I can't seem to find the comment.  

So I think I missed that lecture in residency.  It seems to me that while psychotherapy is about having an honest, trusting relationship (and that is usually a good thing),  it is very different from the relationships we have in our real lives. 

Psychotherapy is about the patient's life.  In some ways, it's a rather narcissistic endeavor (and I don't mean that in a pejorative way, but it just is).  Mostly it goes one way, and aside from the patient asking "How are you?" and perhaps a polite exchange about the therapist's life if the relationship lends itself to that, the session focuses on the problems and concerns of one person, without the expectation that the patient listen patiently or provide support, kindness, insights, or interpretation to the other party. 

Healthy real-life relationships are two-way streets.  And real life people have issues, demands, and problems.  The psychotherapist is a little bit actor, who doesn't generally volunteer his own distress, and who  may certainly have his own very screwed up life!

Oh, but you want to say that the therapist, by listening attentively and being supportive is modeling good listening skills, empathy, and kindness.  Ideally, that's true.  But the therapist is modifying his reactions based on the fact that he's learned a particular style of listening, understands that being non-judgmental is part of the deal, and responds in a way that is therapeutic for the patient.  So he doesn't argue about politics, doesn't get indignant if the patient makes a degrading remark about something the therapist values, and when he confronts the patient with behaviors or thought patterns that need to be changed, he does it from a place that is gentle, respectful, and he backs down if the patient gets upset and can't hear it. In other words, the therapist sometimes quashes his own emotions and reactions for the sake of the patient.   Real life people in two-way relationships just aren't wired to be 'all about you' all of the time.  While a friend may see that you are upset and let you go off ranting (and thank you to my friends who do this for me) and listen nicely and therapeutically for a bit, this is too much to ask from anyone all of the time in a long-term relationship.  People disagree, they argue, they have their own opinions, and they show it when they get offended or angry.  One should not expect the people in their lives to react as their therapists do, in measure ways.  Nor should they hold themselves to that standard when engaged in a relationship with others.  It's nice if you can do it for a little while for a friend/spouse/relative in distress who needs a comforting ear.  But don't go home and try to be your shrink.  It's hard and you won't have any friends. 


Ideally, a psychotherapist is very responsive and reliable.  There are exceptions (oh for the shrink with ADD, or who runs overtime with an emergency, or who is just a bit disorganized), but generally, the doctor shows up.  Probably a good thing to expect in one's important relationships, but it doesn't always work out that way, and there is some motivation for the shrink in that this is "Work" (and many people who are irresponsible in their private lives do prioritize "work") and the shrink gets paid.


On the positive side, in real life intimate relationships, you get to be together for more than an hour, it doesn't cost you big bucks to talk, there's some possibility that you aren't being pushed to talk about things you'd rather not, a hug or a kiss or a reciprocal statement of love can be very wonderful things, as can a card or a gift (chocolate is often good) or an offer to go out for coffee or a drink or a walk, when you're feeling distressed.

Therapists generally don't throw plates against the wall when they get upset with a patient, so if you need that type of adaptive behavior and restraint to be modeled for you, then I agree, the therapeutic relationship does show some healthier ways of responding.

Tell me what you think?   What have your patients said they've learned from you, and what have you learned from your therapist? 

Raising Poochie Right

Okay, healthys know about mental illness, but we are called on to comment all different types of issues regarding relationships, development, what transactions are likely to lead to mental health or mental distress.  I'm expanding our area of so-called expertise even further, and feel inspired to comment on an article in today's New York Times, "Should Your Dog Be Watching TV?"  


Regarding new TV programming made especially for dogs, Douglas Quenqua writes:


If your dog does show interest, it probably can learn from what it sees on a television, Ms. Anderson said. Exposing a pet to muted versions of everyday irritants like vacuum cleaners and doorbells, for example, is a time-tested method for reducing the animal’s fear of them. But an important aspect of the technique is amping up the volume as the dog grows comfortable — so, depending on how quickly a dog learns, the owner may want to hover nearby to turn up the DogTV volume.

But — of course — dog owners shouldn’t mistake TV time for quality time, animal behaviorists cautioned. “It definitely isn’t a substitute for play time with your dog,” Ms. Anderson said. “Exercise can solve a lot of behavioral problems.

Oh my, programming includes  grassy fields, bouncy balls, quiet vacuum cleaners,  scenes to comfort, entertain and teach dogs, and to address anxiety, agitation, and decrease separation anxiety.  It just makes me think that raising children is hard enough and you have to worry about what you expose your children to, how much time they spend in front of screens, whether you're using your TV as a babysitter, how you're going to schedule piano lessons so they don't conflict with tennis team, homework, and religious school.  The nice thing about having a dog is that it just gets to be a dog.  You walk the dog, pet the dog, feed the dog, be with the dog.  Until now, you didn't have to worry about all the influences on the dog: how much TV is the right amount of TV? Is it okay to go for a walk in the woods or will Rover miss an important learning segment on TV?  What if the dog finds some segments soothing  (is he just transfixed?  Is this healthy?) but finds other segments over-stimulating?  Look, yet more things to worry about, as if life wasn't complicated enough.

I may have to trade in the dog for a gerbil and hope they don't invent Rodent TV. 

Shrink Rappers Set Bar High for NAMI Walks

4/24: $250 ~ 4/25: $295 ~ 4/28: $330

Click on image to donate!
See which Shrink Rapper has attracted the most donations.
4/28 (7%): thank you, Carol!
4/25 (6%): thank you Christina, Jesse, Abhishek!

The National Alliance on Mental Illness is the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. They provide education and training programs for consumers, family members, providers, and the general public. Their Family-to-family and Peer-to-peer programs have won awards for providing education, insight, and support to people and families affected by mental health problems. They have hundreds of state and local affiliate organizations to provide grassroots support to communities.

NAMIWalks, NAMI's annual fundraiser, raised charitable contributions to support their work. The Shrink Rappers are working to raise money for the NAMIWalks fundraiser on May 19 at the Baltimore Inner Harbor. All of the money goes to support the Anne Arundel County NAMI affiliate. We did this last year 3 days before the event and managed to still raise $750. We're shooting for $5000 this year.

Anne Arundel county has a population of 588,000 people. Anne Arundel county has 14 psychiatric beds to treat the portion of that 588,000 who require intensive inpatient psychiatric treatment. That comes to 2.4 inpatient beds per 100,000 people. The average number of psychiatric beds in the U.S. is 36 per 100,000 (most recently available data; see other psych beds posts for details). The average number of psychiatric beds in Africa is 3.4 beds per 100,000 population. Anne Arundel county has fewer inpatient resources per capita than Africa. They need our help.

So... I'm asking our dear readers to help out and pitch in. In the last month, we've had 22,000 unique visitors. If only one-fourth of you Shrink Rap visitors gave $1 to our fund-raising campaign, we'd have $5000 for the Anne Arundel county NAMI chapter, which they can put to good use. Please consider clicking the picture above to donate to this cause. Give $1, $10, $25, $50, or even $100... whatever you can. And it's all tax-deductible. (4/25: Sarebear said it won't take less than $10.)

To really sweeten the deal, we will give an autographed copy of our book to any person or organization that donates $250 or more. (Yeah, I know, big deal. Still, it's a token of our appreciation.)

And, if we manage to get any SUPER donations of $1000 or more (!!), we will place an image of your choice (tasteful only) for one month in a prominent place on our blog to celebrate your generous donation (or to advertise your organization), including a link back to your website, as well as four signed copies of our book. Note that we get about 40,000 page views and over 20,000 unique visitors per month -- that's ~2.5 cents per impression! (If we get more than one of these donations, we'll give each one it's own month, in order of receipt of donation, starting with June.)

"Roy, you've talked me into it. Enough already; where do I click!?"

Click right HERE to take you to our team donation page.  Or click on the image at the top of the post. I will change this image daily to update the progress you are making. You will be able to choose which Shrink Rapper you want to honor with your donation (a little friendly shrink competition).

I'll throw in one more thing. Whomever donates the most will get to also have a Guest Post on Shrink Rap, and we'll bring you on as a guest on our podcast, My Three Shrinks. (Can you tell I listen to a lot of public radio?)

Thank you for considering this worthy cause.
~Roy out.

PS: You can also JOIN our Shrink Rappers Team and raise funds yourself. We have room for 27 more "walkers", and you can either walk in person on May 19, or just in spirit (you don't have to be present to raise money, but I must tell you that Clink will be out of town, and Dinah is at best a maybe).

Endless Therapy...and some other stuff, too.

Yesterday's New York Times appears to be dedicated to psychiatric bloggers. I got a head start with the article on SSRI's, but it's going to take me a while to catch up.  Jesse-- can't I get you to post about Richard Friedman's article, "Why Are We Drugging Our Soldiers?"  You're my military buddy!


So I'll start with "In Therapy Forever?  Enough Already."  Oh my.  By Psychotherapist Jonathan Alpert who authored Be Fearless; Change Your Life in 28 Days.  Excuse me, Mr. Alpert, but when is your next opening?  I got me some issues that could use a quick fix.

Alpert writes:

Talk to friends, keep your ears open at a cafe, or read discussion boards online about length of time in therapy. I bet you’ll find many people who have remained in therapy long beyond the time they thought it would take to solve their problems. According to a 2010 study published in the American Journal of Psychiatry, 42 percent of people in psychotherapy use 3 to 10 visits for treatment, while 1 in 9 have more than 20 sessions.

For this 11 percent, therapy can become a dead-end relationship. Research shows that, in many cases, the longer therapy lasts the less likely it is to be effective. Still, therapists are often reluctant to admit defeat.

He goes on to say:

Therapy can — and should — focus on goals and outcomes, and people should be able to graduate from it. In my practice, the people who spent years in therapy before coming to me were able to face their fears, calm their anxieties and reach life goals quickly — often within weeks.

Why? I believe it’s a matter of approach. Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. They need a therapist’s opinion, advice and structured action plans.

Okay, so I'm all in favor of goals and structure and action plans.  But a lot of people come for longer than 10 visits, they aren't all "failures" or stuck in a bad place (some, granted, are), and putting into words what happens in therapy and why it is helpful is really, really hard.  The psychoanalysts invented their own language for what happens in therapy, and it's not one I was ever able to master.  

Okay, so why would therapy take more then 10 appointments, in bullet points:

• Most people don't come to see me to fix a discrete problem.  They usually come because they are uncomfortable with their feelings or behavior patterns --and screaming really loudly "STOP DRINKING" does not seem to work for me, maybe Jonathan Alpert has a better style.  These problems, like depression or anxiety or irritability or mood lability or panic attacks or being really stressed out,  come and go.  The problems don't get 'fixed' with an action plan.  They sometimes get fixed with medicines and therapy often provides some tools for better coping.
• Therapy offers a place to talk about feelings and behaviors that people are not comfortable talking to their friends about.  Sometimes the issues are on-going and a single "dump" isn't enough.  In these cases, therapy offers comfort.  Insurance companies don't want to hear that: we need measurable goals that can be achieved in 3 sessions.  Comforting those who are suffering is not allowed. (Please forgive my sarcasm)
• People usually can generate their own list of action plans and they come to treatment because fixing the problem is complicated and often they have stuff to work through before they can leave the lousy husband, or feel good enough about themselves to quit the job, or perhaps they shouldn't quit the lousy job because while they want to, it pays the bills and they can't find another job.
• Psychiatric problems wax and wane and people need more support when their symptoms are more intense, and less when all is well.  It's not uncommon for people to come in more often during difficult times and less often during the good times.  
• Some people have problems such that they drive people away and have trouble with intimacy.  The therapeutic relationship may fill that void or be a place to examine those patterns.  Sometimes people who don't have problems with intimacy still find the therapeutic relationship to be really useful.
• For people with behavioral issues, therapy provides a degree of accountability that can be very helpful.

Some people come for a few sessions, they feel better, and that's great.  Some people have an on-going mental disorder and regular therapy sessions provides a safety net: a means to monitor moods, anxiety, delusions, hallucinations,  or the stresses in life, and to talk about relationships, all as part of an ongoing process of coping with a chronic disorder and keeping the symptoms in check or catching relapses early.  Some people find it helpful to go to therapy and talk about the thoughts that go round in their heads, and that's about as scientific as I can get for them.  And finally, some people find that the therapeutic relationship adds a level of comfort, introspection, meaning, and focus to their lives that helps them siphon their emotional energies into creative and productive outlets.  (There, I made up my own language).

So if you're a chronic patient and it feels useful, don't worry about it.   You may not even be a failure.  If you're frustrated that therapy isn't helping you to fix what you wanted fixed, go see someone else for a consult and second opinion.   

Lucy!

Yesterday I was on a speaker on a panel at The Annapolis Book Festival.  There were a few glitches--one of the panelists had a family emergency and couldn't make it (--oh, I still have to meet Pete Earley, I was looking very forward to this after all the wonderful things I've heard about him), and the A-V equipment didn't fly and part of my talk begins with a slide show set to music called The Public Face of Psychiatry, that I like to use as a set up for why psychiatry needs blogs and books and an image re-do.  It all went fine despite the missing panelist and AV issues--I showed the slideshow on my computer and it was worked fine. 

The most notable part of the event, however, was that my Co-panelist, Joani Gammill, author of The Interventionist,  came with her emotional support chihuahua, Lucy.  What a sweet little dog!  She also came with her beautiful, charming, and very mature 13-year-old daughter, but the daughter remained in the audience, in charge of the never-used dog carrier.  Lucy, however, was front and center on the panelist's table.   And to think, I actually ironed my shirt that morning.  If I knew there would be a dog to focus all the attention, I would gone wrinkled.  


Joani  and Lucy spoke first while four men worked on the projector on my behalf.  After I spoke, I asked for questions.  The first question, influenced I'm sure by Lucy-- was from someone who wanted to know how I used animals in my practice of psychiatry.  Oh my.  I really can't compete with a chihuahua.  I thought of my dogs, Kobe, the incredibly high strung Pomeranian who appeared in my back yard two-and-half years ago, and Max, the wonderful mutt-from-the-pound who hated closed spaces and died of cancer last year.  I told what few pet stories I had: I'd brought Max to my office once on a weekend.  He panicked in the elevator (we left by the stairs).  He couldn't even sleep in a bedroom with us, he scratched at closed doors.  No therapy for Max.  And Kobe doesn't sit still and would be an amazing distraction.  Kobe, sad to say, is all about Kobe.  And once upon a time I was medical director of a clinic.  One day I looked outside my first floor office window and there was a man on the sidewalk outside the clinic with a 10-foot-long albino python wrapped around his neck.  He wasn't a patient, and I asked him A) what does it eat and B) to leave.  Snakes and community psychiatry clinics don't mix.  A patient once brought a dog to a session with another healthy in her handbag (I don't recall this being a problem).  And another patient brought his pet ferret in.  I asked him not to because there were children in the waiting room petting the ferret and I didn't think it was fair for some poor mom to have to explain to the pediatrician that her kid got bitten by a ferret while she was waiting to see her healthy.  The member of the audience suggested I get a fish tank-- not a bad idea, my dentist has an amazing one--but I struggle to keep the plants alive, arrange separate coverage for them while I'm away, and....well, I'll think about the fish idea.

Okay, so Joani has been to rehab compliments of Dr. Phil, and has continued to work with him in her own role as an interventionist.  You can see why she'd be good, and I put a Dr. Phil clip with her up above.  The Shrink Rappers have an funny fondness for Dr. Phil after  ClinkShrink and Roy tricked me into  believing we were talking to him on the phone during a podcast.   And while, I'm plugging other people, I hope all is well with our missing panelist, Pete Earley, and do check out his wonderful book Crazy: A Father's Search Through America's Mental Health Madness.   


It was a very fun morning.  They gave me a nice gift bag for speaking and told me to take two for my co-authors, so Clink and Roy, I have gifts for you (note to Clink, includes T-shirt and coffee...)  We even sold a few books and I got to be on a panel with a chihuahua.

And if you've never listened to the Dr. Phil prank that my co-bloggers played on me, you can find it here.  Hard to believe I'm advertising how gullible I am.

Do SSRI's Even Work? And if so, How?

Just in case you feel like reading Sunday's New York Times Magazine before it come out, over on "Post-Prozac Nation: The Science and History of Depression," Siddhartha Mukherjee will be writing about the history and efficacy of antidepressants.  Dr. Mukherjee writes:


Fast forward to 2012 and the same antidepressants that inspired such enthusiasm have become the new villains of modern psychopharmacology — overhyped, overprescribed chemicals, symptomatic of a pill-happy culture searching for quick fixes for complex mental problems. In “The Emperor’s New Drugs,” the psychologist Irving Kirsch asserted that antidepressants work no better than sugar pills and that the clinical effectiveness of the drugs is, largely, a myth. If the lodestone book of the 1990s was Peter Kramer’s near-ecstatic testimonial, “Listening to Prozac,” then the book of the 2000s is David Healy’s “Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression.”


He talks about depressed people in the 1950's being cured as a side effect of their treatment for tuberculosis (isoniazid was one of the first medicines to elevate mood in the depressed) and hyptertensive patients becoming depressed on Raudixin.


Mukherjee goes on:

In 2011, Hen and his colleagues repeated these studies with depressed primates. In monkeys, chronic stress produces a syndrome with symptoms remarkably similar to some forms of human depression. Even more strikingly than mice, stressed monkeys lose interest in pleasure and become lethargic. When Hen measured neuron birth in the hippocampi in depressed monkeys, it was low. When he gave the monkeys antidepressants, the depressed symptoms abated and neuron birth resumed. Blocking the growth of nerve cells made Prozac ineffective.

Hen’s experiments have profound implications for psychiatry and psychology. Antidepressants like Prozac and Zoloft, Hen suggested, may transiently increase serotonin in the brain, but their effect is seen only when new neurons are born. Might depression be precipitated by the death of neurons in certain parts of the brain?


He finishes off with the ideas:

The differences in responses to these drugs could also be due to variations in biological pathways. In some people, neurotransmitters other than serotonin may be involved; in yet others, there may be alterations in the brain caused by biological factors that are not neurotransmitters; in yet others, there may be no identifiable chemical or biological factors at all. The depression associated with Parkinson’s disease, for instance, seems to have little to do with serotonin. Postpartum depression is such a distinct syndrome that it is hard to imagine that neurotransmitters or hippocampal neurogenesis play a primary role in it. 

Nor does the theory explain why “talk therapies” work in some patients and not in others, and why the combination of talk and antidepressants seems to work consistently better than either alone. It is very unlikely that we can “talk” our brains into growing cells. But perhaps talking alters the way that nerve death is registered by the conscious parts of the brain. Or talking could release other chemicals, opening up parallel pathways of nerve-cell growth. 

But the most profound implications have to do with how to understand the link between the growth of neurons, the changes in mood and the alteration of behavior. Perhaps antidepressants like Prozac and Paxil primarily alter behavioral circuits in the brain — particularly the circuits deep in the hippocampus where memories and learned behaviors are stored and organized — and consequently change mood.

Over on Clinical Psychiatry News....

Check out our CPN site where Roy is talking about Stage 2 Meaningful Use, and I've put down my final words (I hope!) on strip searching psych patients.  Do Check It Out if you'd like to see what we have to say, and to all those who helped me with this article, please accept my gratitude!  Roy and I would both love your feedback.


Lately, I feel like a moving obsession...I was preoccupied with medical marijuana legislation for a bit, then with how body searches are conducted of our patients, at the moment I'm reading Kaitlin Bell Barnett's new book Dosed: The Medication Generation Grows Up....my review is forthcoming.  What next?

EHRs & Privacy: Am I The Only One Who Cares About This Stuff?

 

Electronic Health Records are a wonderful thing.  They allow for the easy access of information from one doc to another.  Now when the patient takes the white pill for that bump, I can go in to the records and see what the bump was and what the white pill is.  Once in a great while, it has meaning for their psychiatric care, and it's good for general curiosity, too, and periodically, I may help with the education process if it seems important that the patient should have a greater understanding of their bumps.  Roy likes EHRs and President Obama will pay you tens of thousands of dollars to implement one in just the right way (too many hoops for me).  As a doctor, it's mostly nice.  I still see a lot of people who get portions of their health care in another system and I can't access their labs-- labs I actually need to have to safely monitor how their bodies are tolerating their psych meds, but I'm doing my best.  When I run labs on a patient who gets their primary care outside of our system, I hand them a copy to give to their doctor, hoping that I will spare them a needle stick and spare the 'system' (usually Uncle Sam) the cost of repeating the same blood work.  Who knows if that ever happens.


I've mentioned before that my gripe with this system is that any healthcare professional in the system can access information.  Now everyone I work with, and approximately 10% of my neighbors (wild guess here), and even some of my patients,  have access to this system.  The only thing that stops someone from looking up a friend's medical history is the knowledge that you will get in trouble-- and likely fired-- if you get caught.  But you have to get caught, which means that someone has to look up who accessed the information and track down if it was a legitimate accessing of information.  Now they do it, and people have been fired, and the prohibition is real, but we don't think that in a system of many thousands of people, there isn't a sociopath here or there?


Let me give you an theoretical example: what if a young nurse (he has access) starts dating a pretty young hospital worker (she does not have access to the records; also these people can be old and/or ugly if you'd like....just enjoying my fiction here).  He's curious about her; in fact, he's prone to a bit of pathological jealousy.  He decides to take his chances and look up her records and he notices that someone has run an HIV test on her (it was negative) and she's had a miscarriage a couple of years ago, one she never mentioned to him.  Oh, and psych records aren't in the system (yet, coming soon) but her primary care doc mentioned that she's on Prozac for depression and Seroquel for sleep.  Isn't Seroquel the big guns, maybe she's crazy.  So if he tells her he looked at her records, and she wants to report him, he's toast. But maybe she doesn't want to get him fired, so she eats it.  Also, once he's fired, he's just fired, not dead.  He can then tell whoever he likes, I suppose, especially if he loses his license.  And the saying goes that there are random "flags" that go up to catch wrong-doers, but this is a big system, so I am skeptical.


I've mentioned my concern about this to a few people, especially since the system is about to be overhauled.  I've suggested that each patient have a card or an identifier that the provider should get from the patient to authorize access to the information.  I've asked that this be brought up at planning meetings.  I get looks like I'm from Mars.  Obviously, all health care providers should have access to their patient's records, and in this system, there is no absolute guarantee that your neighbor won't be curious and you don't have the right to not tell the dermatologist that you had a vasectomy three years ago, or to keep your internist from making a note that your antibiotic was started in jail.  Okay, I will say that all of the records I've read (it's been years, that's a lot) are very professional, but still, sometimes the facts are the facts and they aren't all that savory.  I asked if the topic came up at the planning meeting and was told no one else was concerned.  My boss has agreed with me that I watch too much 24.


So I went to schedule a routine screening exam the other day.  I have no reason to be concerned about this, but I am generally uneasy about being in the massive data bank that is the system's records and I avoid it.  I called for the appointment, and the office had been taken over by my hospital system, something new!  I asked if my results would go into the main hospital computer.  Of course they will!  Thank you, I said, I will get my test elsewhere, and I hung up. 


Why doesn't anyone else care about this stuff?

Come Meet Dinah!

Dinah will be speaking with Pete Earley and Joani Gammill at

 The Annapolis Book Festival on April 21st.

MATTERS OF THE MIND: MENTAL ILLNESS AND ADDICTION 10:30 a.m. Room 3 - Barn Commons   Mental illness and addiction take many forms. How do we cope as sufferers, as family members, as mental health professionals? Moderated by Joan Gillece, a diverse panel featuring Pete Earley, Joani Gammill and Dinah Miller looks at matters of the mind from their varied perspectives.

The Incarcerated Mentally Ill

Ah, it's a ClinkShrink topic but she's off for the weekend answering a call to the opera, so I'm filling in and posting an article from The New York Times.  Abby Goodnough writes in "Deal to Reduce Isolation of Mentally Ill Inmates,"

The settlement results from a lawsuit filed in 2007 by an advocacy group. It sought to stop Massachusetts from placing mentally ill inmates with disciplinary problems in small isolation cells for up to 23 hours a day, saying that doing so violated their constitutional rights against cruel and unusual punishment as well as the Americans with Disabilities Act.

Poll Results and the Limelight...

Over on Clinical Psychiatry News, Roy is writing about using the color Lime for mental illness awareness...do check it out.  Apparently it works for Lyme Disease, Lymphoma, and Muscular Dystrophy, too, but here in psych we like to be inclusive and co-morbidity is always an issue.

If you took my poll on patient searches or helped with comments I can use for quotes, thank you so much.  The survey results are here, please remember these are not science, not even a little, and I left it to the reader to define "strip search" so it's really just a snapshot:

Were you Strip Searched upon admission?
	Yes 27 42% No. 38 58%

If you answered YES: Were you a voluntary patient at the time of admission?
	Yes 20 31% No 9 14%

If you answered YES: What type of hospital were you in?
	Private Psychiatric Hospital 11 17% A Psychiatric Unit of a Community Hospital 14 22% A State Psychiatric Hospital 6 9% A State Hospital specificially for Forensic/ court-ordered patients 0 0%

If you answered Yes, did you find the experience of being strip searched to be very distressing?

I hope no one is offended that I discussed two things in one post. I know people were offended in the past, but late on a Friday, you only get two posts when my salary for this goes up.  If I'm not back, have a great weekend. 

Tell Me Your Psych Unit Search Stories

I'm planning to write an article on strip search policies at psychiatric hospitals and that's why I asked anyone who has been hospitalized in a psychiatric unit in  the last three years to take my Strip Search Survey.  Roy pointed out to me that I didn't define 'strip search' and that his hospital does not do this---they ask patients to change into a gown and search their clothes, but not their bodies.  I did assume that people would define strip search as the visual inspection of the skin after the removal of all clothes, and that being told to change with some sort of privacy --in a bathroom, behind a curtain, while a nurse of the same gender holds up a gown or a sheet but isn't looking-- is not a strip search. 


Will you help me with my article?  Can you tell your stories in the comment section and let me quote you?  I will not use 'names' but quote "one commenter said,"  and you are welcome to give your feedback as "Anonymous."  I would like to know what state the hospital you're talking about is in, and if you are a patient, a healthy, a nurse, a family member.  I'm interested in stories of how being searched was handled well and how it was handled badly, stories by hospital personnel.  I know some of you have told your stories here before, but I didn't ask for permission to quote, so feel free to repeat yourself here if you don't mind being quoted.    Also, if you were strip searched, I'd like to know if it was because of a blanket policy at the hospital versus a specific concern the staff had about you and any danger you might pose to yourself or others.

Neurotic

Benedict Carey has a good read in last week's New York Times about the gradual disappearance of the Freudian term "neurotic," as in "The neurotic is always half-drowning in anxiety, and always being half-rescued." (Mignon McLaughlin, The Neurotic's Notebook, 1960).

Carey's analysis reviews the history of this term, and explains how is was expelled from the DSM back in 1994. He quotes Michael First, MD, "With the general decline of value of Freud in our society, it is ultimately anachronistic." In fact, it made me realize that I almost never use this word. When I do hear it in a professional context, especially as a noun referring to a person, it is generally by someone a good 15 years my senior.

healthys don’t ultimately shape the language we use, after all — we all do — and neurosis has at least as much going for it as other Freudian keepers, like ego and id.

 And I never hear about, nor talk about, the id.

So, the story talks about how we used to put everything into the neurotic bucket, but have since split things up into multiple, more narrowly-defined, terms, such as social phobia, generalized anxiety disorder, and obsessive-compulsive disorder. These used to all fall under the neurotic label.

The good part about this change is that defining these types of anxiety disorders has led to improved treatments, and has allowed us to accept more common, less disabling, concerns as just a spectrum of normality. Carey points out, though, that our new technologies have turned many of us into unlabeled neurotics.

But another way to read those numbers is not as a measure of mental makeup but of cultural change. People of all ages today, and most especially young people, are awash in self-confession, not only in the reality-show of pop culture but in the increasingly public availability of almost every waking thought, through Facebook, Twitter and other social media.

If chronic Facebook or Twitter posting is not an exercise in neurosis, then nothing is.

I Need Your Help

If you've been admitted to a psychiatric hospital in the last three years, please take my survey by clicking HERE. It will only take a moment, and I'd like to use the responses to write an article.  Thank you!

Strip Search Survey

Okay, if you've been reading our blog for long, you know that there are some sensitive issues here, and strip searching patients upon admission to psychiatry units is one of them.  I'm a healthy and I didn't know this was routine.  Of course, I assumed it happened if someone was presumed to be dangerous, so if they have a weapon taken from them in the ER, a history of violence, or are being admitted to a locked unit for their own safety.  But grandma with her agitated depression?  Or a high school student with an eating disorder?   One thing that's changed since I was a resident (the last time I worked on an inpatient unit) is that admission criteria has changed significantly.  There are few elective admissions, and pretty much the only way that insurance will pay for admission is if the patient is an imminent danger, so this means that the patients on the inpatient unit are, by definition, more likely to be dangerous and acutely ill.  When I was in medical school, people were admitted for depression for weeks, they'd go out on passes to see how they did at home or away from the unit, and admissions were planned for "next Wednesday."  I remember one patient was admitted for chronic insomnia.  On the Sexual Behaviors unit, people would be admitted for evaluation-- was the old guy who touched his niece when he was drunk a pedophile, or was this an unusual behavior inspired by the fact that he was drunk?  Was he a danger?  And someone could be admitted (electively) for urges to commit sexual offenses.  Things have changed.  So maybe it's not that outrageous to strip search someone who's admitted because they are imminently dangerous, or maybe it is---our readers comment about the trauma of it, how it deters them from being hospitalized when they should be, about feeling violated and having old sexual traumas evoked.  


If hospitals have different policies and they don't have different rates of violence with weapons/ problems with smuggled drugs, then changes should be made.  Some readers have written in about more sensitive means of searching patients, and Clink now thinks hospital should employ trained, cute, dogs to sniff out contraband.  I'm all for it.  What about those with dog allergies?

Strip Search

A while back, one of our readers wrote a comment discussing the distress of being strip searched upon admission to a psychiatric facility. The reader felt this was particularly egregious because she had been a victim of sexual abuse and this insensitive treatment, unnecessary in her case, caused her to relive the distress of past sexual abuse and psychiatry should be about healing, not opening wounds and causing pain and suffering.


I felt badly for our reader.  In fact, I felt badly for anyone put through such a practice, but I suppose I understand that outrageous and dangerous things happen in psychiatric hospitals and this could be a no win situation: what about the person who is assaulted by a patient who had a razor taped to their inner thigh that went undetected...wouldn't that patient feel it was awful that no one had searched the perpetrator?  And staff on psychiatric units are not uncommonly assaulted, shouldn't they have the right to do what's necessary to protect themselves?  I'm not sure that includes strip searches, but I suppose if there's a couple of stories of contraband or weapons or drugs being sneaked in, then policies change.  One guy has an explosive in his sneakers 9 years ago, and millions of people are taking off their flip-flops every day in airports.  I can't say that particular practice ever made me feel safer.


Okay, I also didn't know that psychiatric units strip search patients.  I haven't worked on an inpatient unit in many years, and if this occurred, I imagine it was done by the nurses, if at all.  Back then, I never heard a patient complain about this or even mention it, and in the years since, I've never had a patient mention being strip searched during an admission.  I'm guessing that it's not a universal phenomena?  Actually, I'm guessing that most hospitals don't strip search psychiatric patients, and really, if they do, I'd be pressed to know why just psychiatric patients, many people in hospitals have histories of unsavory behavior.  


Okay, so just in case I'm not appalled enough, yesterday the Supreme Court, in  Florence v. Bd. of Chosen Freeholders  voted that anyone who is arrested, for even the most minor of crimes-- walking your dog without a leash,  jay-walking, you name it--can be strip searched before being placed in jail.  The court says that even minor violators can be dangerous, and note that Timothy McVeigh was arrested for driving without a license and one of the 9/11 terrorists was stopped for a traffic violation.  Would strip searching them have stopped their terrorist attacks or prevented any future bad events?  As doctors, we think in terms of risk, evidence-based medicine, best practices, statistical events, not anecdote, but I'm convinced that anecdote is much more powerful than science.  And I don't think this supreme court decision bodes well for treating psychiatric patients any more humanely-- if it's no big deal to strip someone who didn't pay a traffic fine (for example, Mr. Florence in the above named case, but oops, he actually did pay the fine years earlier and there was a computer error, oh my), then I can't see why there would be sympathy for the dignity of anyone else.

I'm Right Here!

So I saw the title of a New York Times article by Benedict Carey, "Where have all the neurotics gone?" and I thought, "Wait, I'm here, who's looking for me? 


It's a strange article, lacking cohesion, just so you know.  I'm not really sure what it's actually about.  

It meant being interesting (if sometimes exasperating) at a time when psychoanalysis reigned in intellectual circles and Woody Allen reigned in movie houses.

That it means little now, to most Americans, is evidence of how strongly language drives the perception of mental struggle, both its sources and its remedies. In recent years healthys have developed a more specialized medical vocabulary to describe anxiety, the core component of neurosis, and as a result the public has gained a greater appreciation of its many dimensions. But in the process we’ve lost entirely the romance of neurosis, as well as its physical embodiment — a restless, grumbling, needy presence that once functioned in the collective mind as an early warning system, an inner voice that hedged against excessive optimism. 

Okay, what exactly does that mean?  I think of being 'neurotic' in lay (not healthy) terms as being someone who worries about things that aren't likely to happen, in a way that makes them, and me, uncomfortable.  Do you want to hear how much I worried about exams in college and medical school?  Or how anxious I've gotten when one of my kids doesn't answer a phone call, even though I rationally know that everything is alright?  And I could give you long lists of the really strange things some of my friends worry about and they think it's perfectly reasonable that they worry about these things (and these are my friends, not my patients).  So if you're looking,  I'm right here, in good company.

Carey goes on to talk about how the term has evolved with the DSM, and the 5-factor personality inventory (the NEO, invented by Paul Costa, who somehow doesn't get a nod in the article, but I'll give him one!)  Apparently, college students are more neurotic than ever.  Hard to believe, but if you say so.

But another way to read those numbers is not as a measure of mental makeup but of cultural change. People of all ages today, and most especially young people, are awash in self-confession, not only in the reality-show of pop culture but in the increasingly public availability of almost every waking thought, through Facebook, Twitter and other social media.

If chronic Facebook or Twitter posting is not an exercise in neurosis, then nothing is. 

Funny, he says nothing about blogging..... And he could have ended the article here, but instead he goes on to talk about how it's more normal to be neurotic, "more garden variety troubled than really troubled..."  or something like that, but then the article goes on to differentiate anxiety from depression and talks about mood disorders and how people might not want their children to marry the child of a parent with mental illness.   I think he should have ended the article with the idea that all the neurotics have gone to change their Facebook statuses, except for those people who are too neurotic to have a Facebook page.

Okay, I'm off to tweet this.